Strategic Road Maps
Each of the three key driver diagrams provided to be used at the state, health plan and health system levels is accompanied by a Strategic Road Map that identifies tools, workbooks, resources, and suggested actions for the respective strategies presented. The Strategic Road Maps were developed by QMETRIC based on learnings throughout the PQMP project, which included multi-stakeholder design meetings. The Strategic Road Maps are available in the tables below and for download as PDFs at the following links:
- State Medicaid Program Strategic Roadmap (PDF, 85 KB).
- Health Plan Strategic Roadmap (PDF, 91 KB).
- Health System Strategic Roadmap (PDF, 150 KB).
Table 1. State Medicaid Program – Strategic Road Map
| Key Drivers | Strategies - Change Ideas | Tools, Resources, Suggested Actions |
|---|---|---|
| Health Plan Incentives to Promote TCD Screening & Follow Up | Financially incentivize Medicaid health plans to increase the percentage of children with sickle cell anemia that receive an annual TCD screen by XX% over baseline in 12 months |
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| Engage & Monitor TCD Screening QI Efforts | Identify health plan baseline performance rates and processes aimed at improving care for children with sickle cell disease, including increasing TCD screening rates |
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| Develop process for health plans to report new processes/ activities aimed at improving care, including increasing TCD screening rates | ||
| Provide measure performance feedback to Medicaid and CHIP health plans on regularly scheduled basis | ||
| Establish processes for health plans to share best practices for improving care, including increasing TCD screening rates, with one another |
Table 2. Health Plan – Strategic Road Map
| Key Drivers | Strategies - Change Ideas | Tools, Resources, Suggested Actions |
|---|---|---|
| Activate Care Management Strategies | Pediatric members with SCD are assigned a health plan care manager |
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| Communication process is established between clinic staff and health plan care managers to ensure care coordination (e.g., pre-approvals, transportation, no-shows, unable to reach) |
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| Care managers receive education regarding sickle cell disease and necessity of preventive care including TCD screening for children with sickle cell anemia |
Educational resources from the NIH, Sickle Cell Disease News, NYU Langone Health, Michigan DHHS, and the Sickle Cell Disease Association of America are available at the following webpages: |
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| Health plan staff develop a registry of pediatric members with SCD which tracks PCP/hematologist visits, medications, ED visits, and other healthcare related activities including TCD screening |
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| Registry is used to identify members who require annual TCD screen |
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| Care manager contacts member (text, email, postal mail, phone call) to discuss scheduling a clinic visit |
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| Care manager provides educational materials which explain reasons for/value of preventive care including TCD screening for children with sickle cell anemia |
Educational resources from Sickle Cell Disease News, NYU Langone Health, Michigan DHHS, and the Sickle Cell Disease Association of America are available at the following webpages: |
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| Facilitate Patient Clinic Visits | Care manager assists in scheduling appointment, as necessary |
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| Care manager identifies and note patient’s preferred method and frequency for appointment reminders |
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| Care manager sends patient appointment reminders (text, email, postal mail, phone call) depending on patient preference |
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| Care manager assesses potential barriers to care and provides assistance with transportation, other needs |
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| Care manager contacts member to assist in rescheduling missed/cancelled appointments, identify barriers to attending appointments/ obtaining care |
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| Care manager implements “unable to reach” protocol for members who are not reached within a specified number of attempts |
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| “Unable to reach” protocol includes home visit to identify barriers to obtaining care |
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| Train & Support Providers | Health plan staff provide training and educational materials to providers regarding sickle cell disease and necessity of preventive care including TCD screening for children with sickle cell anemia | Educational resources from the NIH, Sickle Cell Disease News, NYU Langone Health, Michigan DHHS, and the Sickle Cell Disease Association of America are available at the following webpages:
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| Health plan staff provide clinic staff with feedback on rates of children who received TCD screening (quality measure performance) |
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| Support Patient with TCD Scheduling & Screening | Care manager sends patient reminders (text, email, postal mail, phone call) to schedule TCD screening |
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| Reminders include educational materials which explain reasons for/value of preventive care including TCD screening for children with sickle cell anemia |
Educational resources from Sickle Cell Disease News, NYU Langone Health, Michigan DHHS, and the Sickle Cell Disease Association of America are available at the following webpages: |
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| Care manager assists with scheduling appointment, as necessary |
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| Care manager assesses potential barriers to care and provides assistance with transportation, other needs |
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| Care manager follows up after specified time period following provider order to determine if TCD screen was obtained |
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| Care manager contacts member (text, email, postal mail, phone call) to schedule/reschedule TCD screening if not received within specified time period following date of provider order and identify barriers to attending appointments/obtaining care |
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| Follow-Up | Care manager contacts member/clinic staff to obtain results |
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| Care manager contacts member to assist with next steps in care, as necessary |
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Table 3. Health System – Strategic Road Map
| Key Drivers | Strategies - Change Ideas | Tools, Resources, Suggested Actions |
|---|---|---|
| Identify Patient and Conduct Outreach | Clinic staff create and maintain sickle cell disease (SCD) patient registry to identify gaps in care (e.g., past due screenings) and enable QI processes |
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| Clinic staff identify patients without a provider visit within 1 year |
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| Clinic staff send patient reminders (text, portal reminder, email, postal mail, phone call) to schedule clinic appointment |
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| Reminders include educational materials that explain reasons for/value of preventive care including TCD screening for children with sickle cell anemia | Michigan DHHS, and the Sickle Cell Disease Association of America are available at the following webpages: | |
| Communication process is established between clinic staff and health plan care managers to ensure care coordination (e.g., pre-approvals, transportation, no-shows, unable to reach) |
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| Clinic staff hold weekly team meeting for pre-visit planning for patients being seen during week – review date of last TCD screening to determine if TCD screen is due |
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| EHR reminders are created that prompt the provider to review date of last TCD screening and order TCD screening, if necessary |
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| Standardized order set that includes annual TCD screening is established |
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| Conduct Patient Clinic Visit & Education | Clinic staff identify and note patient’s preferred method and frequency for appointment reminders |
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| Patient attends clinic visit - Provider reviews last TCD screening date, orders TCD screen |
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| Patient preventive care education, including rationale for TCD screening, is provided during visit | Educational resources from Sickle Cell Disease News, NYU Langone Health, Michigan DHHS, and the Sickle Cell Disease Association of America are available at the following webpages: | |
| Clinic staff provide health plan care manager contact information, share information regarding care management services |
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| Clinic staff provide instruction for using patient portal to schedule appointments, ask questions, review test results |
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| Clinic staff schedule next clinic appointment at end of visit |
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| Clinic staff implement process to reschedule missed/ cancelled appointments |
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| Support TCD Scheduling & Screening | Clinic staff assist patient with scheduling TCD screening appointment at end of clinic visit |
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| Clinic staff send patient reminders to schedule TCD screening (text, portal reminder, email, postal mail, phone call) depending on patient preference |
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Multi-Stakeholder Approach to SCA Quality Improvement
QMETRIC hosted two in-person and multiple virtual expert design meetings to identify potential quality improvement (QI) interventions to deliver high-quality preventive care for children with sickle cell anemia (SCA). This group, known as the Sickle Cell Trailblazers, consisted of representatives from all partner health systems, health plans and the State Medicaid program, as well as parents of children with sickle cell disease and patients themselves. Through planned discussions during these meetings, participants laid out a common vision for an ideal future state of SCA preventive care, identified gaps in knowledge across stakeholders, and brainstormed dozens of potential interventions. These discussions identified multiple gaps in knowledge about the many barriers faced by families and resources available across stakeholder groups, which in itself represents a significant barrier to the delivery of coordinated, efficient, appropriate preventive care. The vision of ideal care that emerged from the design meetings is noteworthy as it calls for personalized, individual care for people with SCA and their families.
In terms of learning across stakeholders and brainstorming potential interventions, each participant contributed an important perspective to the design meetings, emphasizing the need for community approaches to improve care for children with SCA. First and foremost, SCA patients and parents provided unique insights into the challenges of obtaining high-quality preventive care. The participants were greatly moved by the parent stories as most (other than the clinicians) had never met a parent of a child with sickle cell disease nor an actual sickle cell patient. Importantly, the families who had the interest, time, and resources to join the design meetings recognized that they are empowered to advocate for their children. This may be in contrast to many families affected by SCA who may not have the knowledge and resources to advocate for themselves in the same way, a message echoed by community leaders.
The output of the design meetings was a framework for idealized care of the sickle cell disease population and ultimately, a series of key driver diagrams at each level to improve care. A complete description of the design of the two in-person meetings may be found in the published manuscript “Designing a Multistakeholder Collaboration to Improve Preventive Care for Children with Sickle Cell Anemia.” (Bates KE, et al., 2019).
The Director of the Michigan Department of Health and Human Services Managed Care Plan Division, Quality Improvement & Program Development Section was greatly moved by the personal stories of parents and patients at the design meetings. There was also a strong sense of a social justice imperative for these children among the staff in that office. Recognizing the need to improve care for these children, the Director and his staff have taken the action and are developing an incentive program for Michigan Medicaid health plans to improve the care of their members with sickle cell disease. The state plans to use its financial incentives “lever” to encourage an environment for plans within a specific Medicaid region to work collaboratively to improve measure performance for all children in that region, regardless of their plan affiliation. QMETRIC is helping the State develop this “first in the nation” health plan collaborative for the care of children with sickle cell disease. The fact that the State is willing to devote a portion of the financial incentive pool to sickle cell quality measures is unique and has great potential to improve care.
References
Bates, Katherine E.; Davis, Corinne S.; Reeves, Sarah L.; Freed, Gary L. Designing a Multistakeholder Collaboration to Improve Preventive Care for Children with Sickle Cell Anemia. J Pediatr Hematol Oncol 2019 Nov 12. doi: 10.1097/MPH.0000000000001666.
Hassenfeld Children’s Hospital. Diagnosing Sickle Cell Disease. NYU Langone Health. Retrieved from https://nyulangone.org/conditions/sickle-cell-disease-in-children/diagnosis.
Michigan Department of Health and Human Services. Sickle Cell Disease Family Fact Sheet. Michigan Newborn Screening Program. Retrieved from https://www.michigan.gov/documents/mdch/Sickle_Cell_Fact_Sheet_465285_7.pdf.
Michigan Department of Health and Human Services. Michigan Medicaid Health Plan Listing by County. Updated January 2020. Retrieved from https://www.michigan.gov/documents/mdch/MHP_Service_Area_Listing_326102_7.pdf.
Sickle Cell Disease Association of America. Resources & Educational Materials. Sickle Cell Disease Educational Repository. Retrieved from http://sicklecelldisease.net/resources-educational-materials/.
Sickle Cell Disease. National Heart, Lung, and Blood Institute. Retrieved from https://www.nhlbi.nih.gov/health-topics/sickle-cell-disease.
Transcranial Doppler Ultrasound Screening. Sickle Cell Disease News. Retrieved from https://sicklecellanemianews.com/transcranial-doppler-ultrasound-screening/.
