A Care Coordination Q&A with Adebola Adeleye

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Dr. Adebola Adeleye, CMS
Dr. Adebola Adeleye, CMS

Dr. Adebola Adeleye is an Advanced Practicing Nurse who currently works as a Nurse Consultant at the Centers for Medicare and Medicaid Services (CMS). In this role, she serves as the Government Task Leader for the Coordination of Care Task for the Quality Improvement Organization (QIO) Program. Her primary responsibilities include serving as a subject matter expert, and overseeing Quality Innovation Network-QIOs’ (QIN-QIOs) quality improvement efforts in the areas of care transitions and coordination of care for Medicare beneficiaries.

Prior to joining CMS, Dr. Adeleye worked as a Care Transitions Nurse Practitioner with a Community-based Care Transitions Organization in Maryland. In that capacity, she helped establish care transition programs in several hospitals and worked with them to identify the causes of readmissions and to implement strategies to prevent unnecessary admissions and readmissions. She also provided supervision and leadership to the staff at the organization. As a Family Nurse Practitioner, she has a wide range of clinical experience with pediatrics, adult medicine and geriatrics.

Dr. Adeleye recently completed her Doctor of Nursing Practice (DNP) Program at Monmouth University, West Long Branch, N.J. She holds a Masters of Science degree in Nursing (Family Nurse Practitioner Track) from Monmouth University and a Bachelor of Science degree in Nursing from Bloomfield College, Bloomfield, N.J. Dr. Adeleye maintains her clinical practice as a Nurse Practitioner and serves as an Adjunct Faculty member at the University of Maryland’s School of Nursing.

Q. What were some of the accomplishments achieved by the QIO Program in the area of Care Transitions from 2011-2014?

A. Our Care Transitions work during that time period was known as Integrating Care for Populations and Communities.” Our aim was to reduce avoidable hospital admissions and readmissions, and to improve the coordination of care for Medicare beneficiaries transitioning from one care setting to another. QIOs built multi-stakeholder community coalitions serving a geographically defined set of beneficiaries nationwide to carry out their work. More than 14 million Medicare beneficiaries resided in the communities served by the QIO Program. Working in collaboration with partners, QIOs contributed to health cost savings of nearly $1 billion by preventing avoidable hospital admissions and readmissions. The Program prevented over 95,000 beneficiaries from being admitted to the hospital and over 27,000 beneficiaries from being readmitted.

Q. Provide us with examples of how the QIN-QIOs are helping build powerful community infrastructures that safely transition a patient from one care setting to another. 

A. A big focus of QIN-QIOs’ current care coordination work involves community organizing and implementation of evidence-based interventions to improve the quality of care as individuals navigate the health care system. Each QIN-QIO is targeting Medicare Fee-for-Service beneficiaries that reside within specified zip codes in their states, and working with community partners and stakeholders within those communities. QIN-QIOs are engaging stakeholders in communities to identify challenges in cross-care settings and to implement and measure the impact of interventions targeted at improving those problems.. Within these communities, QIN-QIOs are focusing improvement efforts on individuals residing in rural areas, including high-risk individuals who have multiple chronic health conditions, behavioral health conditions, Alzheimer’s and other dementia disorders, socio-economic disadvantages, and dual eligibility for Medicare and Medicaid.

"Working in collaboration with partners, QIOs contributed to health cost savings of nearly $1 billion by preventing avoidable hospital admissions and readmissions."

Q. What role do community partnerships play in the QIN-QIOs’ care coordination work? 

A. Community partnerships are vital to the QIN-QIOs’ care coordination work. State and local government offices, patient advocacy groups, Area Agencies on Aging, pharmacists and organizations like Meals on Wheels are examples of community-based organizations that provide valuable resources and services to beneficiaries. QIN-QIOs work to engage these organizations in community improvement efforts to ensure that providers like hospitals, nursing homes, home health agencies and hospice care providers connect beneficiaries to the resources they provide. When patients transition from one care setting to another – such as from hospital to home health care – communication and coordination among providers and community health organizations are necessary to reduce the risk of patients receiving fragmented or duplicative care, and having poor health outcomes.

Q. Tell us how QIN-QIOs are working to improve medication safety through the care coordination communities.

A. Medication safety is really essential to care coordination. Many Medicare beneficiaries take multiple prescription medications and see multiple providers. We need to ensure the safety of these beneficiaries in all care settings. Our QIN-QIOs are focusing their improvement efforts on those beneficiaries using three or more medications, including high-risk ones like anti-coagulants, diabetic agents and opioids. To do so, they are recruiting and working with pharmacies – including retail, ambulatory and hospital pharmacies – to improve medication safety and reduce adverse drug events (ADEs). ADEs contribute to hospital admissions and readmissions, so preventing them is important to achieving the QIO Program’s care coordination goals.

Q. What national level partnerships or initiatives connect with the work of the QIN-QIOs?

A. QIN-QIOs are working in alignment and in partnership with other CMS and non-CMS programs like Partnership for Patients, the Center for Medicare & Medicaid Innovation’s Community-based Care Transitions Program, CMS payment and incentive programs, the Agency for Healthcare Research and Quality, and the Administration for Community Living. QIN-QIOs are using evidence-based tools and proven interventions like Boston University Medical Center’s Project Re-Engineered Discharge (Project Red), Eric Coleman’s Care Transitions Intervention® and Florida Atlantic University’s INTERACT tools to accomplish their goals. For our ADE work, we are aligning with the National Action Plan for ADE Prevention. QIN-QIOs are also partnering with schools of pharmacy, patient safety organizations and many others.

Q. Anything else you would like QIO News readers to know?

A. The QIO Program is embracing a holistic approach to patient care, looking beyond pure medical conditions to focus on the individual as a whole. We are focusing on the full scope of beneficiary needs, including their socio-economic status, literacy level, caregiver support and other issues, to understand what exactly is contributing to hospital admissions and readmissions. We need to engage all stakeholders who provide care to patients in different settings. We also need to empower beneficiaries to be active in their own care and prepare them to manage their health after discharge. The QIN-QIOs’ work really addresses these needs. Each one of us is a stakeholder in this work. In the end, we all need to advocate for the care that we and our loved ones would want.