The Primary Care Coalition of Montgomery County, Maryland was founded in 1993 when a group of physicians and health care officials imagined a Montgomery County where every resident had access to high-quality health services. They envisioned a dependable source of primary care for low-income, uninsured individuals in our community and created a framework that shared the responsibility for providing that care across the public and private sectors. The Primary Care Coalition (PCC) was formed to help make their vision a reality.
The mission of PCC is to be the catalyst for developing and coordinating a community-based healthcare system that strives for universal access and health equity for underserved community members. The vision of PCC is that all community members have the opportunity to live healthy lives, and that Montgomery County will be the healthiest community in the nation and a model for providing access to high quality and efficient care for all.POSITION SUMMARY
The Director Quality and Outcomes supports the Nexus Montgomery Regional Partnership (NMRP), a $7.6M collaborative effort among the six hospitals operating in Montgomery County and a network of community-based organizations, with the goal of reducing avoidable hospital use by connecting people to community services that optimize health and independence. The Primary Care Coalition (PCC) serves as the management and implementation infrastructure for the NMRP under the direction of the NMRP Board of Managers (representing each of the six member hospitals), the NMRP Finance Committee, and the NMRP Partnership Program Interventions Committee (P-PIC). NMRP outcomes include: reduced hospital admissions, readmissions and emergency department (ED) visits and reductions in hospital costs and total cost of care. The initial programs of the NMRP are:
- Wellness and Independence for Seniors at Home (WISH): a pre-emptive health coaching service for Medicare Seniors living independently in community. Primary goal is to reduce potential hospital utilization.
- Hospital Care Transitions (HCT): 30 90-day care coordination programs implemented uniquely by each of the six NMRP member hospitals and supported by a PCC facilitated Learning Collaborative where hospitals share outcomes and best practices. Primary goal is to reduce hospital readmissions.
- Severely Mentally Ill (SMI); community capacity expansion and system improvement. Primary goal is to reduce hospital utilization and increase use of community based services.
- Uninsured: provides low or no cost specialty care for ineligible-uninsured patients following a hospital interaction. Primary goal is to reduce hospital utilization and readmissions.
- Skilled Nursing Facility Alliance (SNF Alliance): a collaborative, data-driven program to improve care transitions and outcomes for patients who are discharged from a hospital to a SNF for short-term rehabilitation prior to returning home. Primary goal is to reduce readmissions and total cost of care.
In addition, Nexus Montgomery continues to develop and review other potential programs that align with the overall goals of the collaborative.PRIMARY RESPONSIBILITIESP-PIC
: The P-PIC meets monthly to establish and monitor key Nexus Montgomery performance and outcome metrics, monitor needed quality improvement initiatives, evaluate and recommend proposed projects, and ensure that the Nexus Board has the information needed for informed decision-making.
Hospital Care Transitions Learning Collaborative:
- Support P-PIC in the development of performance and outcome measures for all NMRP programs. Refine the metrics' technical specifications; assess availability and timeliness of relevant data. Reconcile outcomes metrics required by HSCRC with measures tracked by P-PIC. Educate P-PIC and Partnership Director on assumptions and relationship between P-PIC measures and HSCRC measures.
- Work with CRISP, HSCRC, QIO, member hospitals, and others to obtain access to data needed for measures.
- With data management and analytics staff, gather measures data from multiple sources; assure data integrity, privacy and security. Implement procedures for regular updates to measures. Perform or interpret quantitative analyses. Prepare routine and ad hoc reports for internal and external stakeholders.
- Assist P-PIC in interpretation of measures and in creating recommendations to the NMRP Board for program investments. At least annually, provide P-PIC with a summary of literature review on programs with evidence of positive impact on hospital or total cost of care.
- Serve as primary staff liaison to P-PIC. Plan meeting agendas with P-PIC Chair. Ensure meeting materials are distributed, minutes are maintained, PD/VP is informed of actions or recommendations, and staff follow-up activities are completed.
Facilitate regular meetings and quality and process improvement activities among participating care transition, care coordination programs and other stakeholders to achieve reductions in avoidable hospital admissions/readmissions and ED use. Maintain minutes and insure follow-up of issues to completion.
- Plan, coordinate and facilitate regular collaborative learning activities among the six hospital care transition programs, including WISH program as appropriate.
- Promote the sharing of challenges, lessons learned, best practices or other models from regional or national care coordination programs that serve to maximize the effectiveness and efficiency of individual care transition programs. Provide process improvement technical assistance and consultation when requested by individual hospitals.
- When appropriate, encourage development of common solutions or programs, promoting innovative design of community 'utilities' for care coordination, care transitions, chronic care management, that address clinical and social determinants of health.
- Draft approach and resource plans to address challenges that require the engagement of community stakeholders beyond the HCT. With manager and peers, assess staff capacity and budgets to implement plans. Provide leadership for improvement effort and technical assistance as directed.
Facilitate regular meetings and quality and process improvement activities among hospital participants and participating SNFs to achieve reductions in avoidable hospital admissions/readmissions and ED use. Promote ongoing participation among SNFs. Maintain minutes and insure follow-up of issues to completion.
- Plan, coordinate and facilitate regular Alliance learning activities among the six hospitals and participating SNFs.
- Arrange for acquisition of relevant quality data and leverage data to promote the sharing of challenges, lessons learned, best practices or other models from regional or national care coordination programs that serve to maximize the effectiveness and efficiency of care provided to patients who are discharged from hospitals to SNFs for short-term rehabilitation. Provide process improvement technical assistance and consultation when requested by individual hospitals.
- Facilitate resolution to intra-program inefficiencies among the many patients shared across hospitals and SNFs.
- Develop measures of success and insure that Nexus Montgomery is able to measure outcomes and demonstrate success where appropriate.
MINIMUM QUALIFICATIONS, SKILLS AND ABILITIES
- Support VP/Director in communications to the NMRP Board, HSCRC and other external stakeholders on programs performance, outcomes and recommendations; address impact on short-term and longer term population health goals and opportunities. As delegated by VP/Director, represent Nexus Montgomery Regional Partnership to external agencies and organizations.
- Identify and build opportunities for collaboration with local, State and Federal organizations, academic centers involved in health care management and quality improvement efforts, and others to further regional reductions in hospital and total cost of care, ensure positive patient experience, and improve population health.
- As time permits, engage with the PCC leader of Quality and Improvement to serve as peer mentors to staff to further develop PCC's culture of quality and improvement. Participate in other PCC collaborative improvement programs, such as the Safety-Net Medical Directors' clinical quality/HEDIS measures.
- Perform other duties as assigned.
- Professional Licensed Clinical Experience preferred (e.g. Physician, Physician Assistant, Nurse Practitioner, Registered Nurse or equivalent); must have knowledge and clinical experience to engage in improvement discussions involving specific clinical diagnoses.
- Demonstrated experience in process improvement with ability to work as a consultant, facilitator and colleague with multidisciplinary healthcare professionals.
- Demonstrated advanced communication skills. Ability to communicate effectively and persuasively, both orally and in writing to a broad range of stakeholders, including clients, clinicians, hospital administrators, and public health officials. Prepare and deliver effective presentations. Listen actively, build rapport easily, identify conflict and tension and facilitate constructive resolution, inspire and build trust.
- Demonstrated advanced analytical skills. Experienced in definition of outcomes and process measures and reporting. Familiarity with data collection/data analysis and relational data base functionality sufficient to direct data management and data analysis staff. Ability to effectively prepare concise reports and presentations of clinical outcomes for internal and external audiences.
- Ability to organize, develop, implement, monitor and evaluate professional work plan goals and performance objectives. Must have excellent organizational skills and attention to detail.
- Ability to lead, facilitate and work with diverse groups. Experienced in creating engaging, non-judgmental meeting environments that encourage sharing of challenges and failures and supportive peer-to-peer learning.
- Computer literacy with proficiency and expertise in Microsoft Office, including WORD, EXCEL, and PowerPoint.
- Self-motivated individual with the ability to work independently and with minimal supervision.
- Public Health or Hospital Quality Improvement experience is preferred.
- Care Coordination/Care Transitions experience is preferred.