Communicare Intervention Assessment

Internal Characteristics

What are the characteristics of your health center? (rural/urban; other demographic variables)?  

Our health centers are in both urban and rural areas. 70% of patients are 100% and below poverty line; 73% are insured by Medicaid/Medicare; 54% are Hispanic or Latinx; 18% of our patient base comprise of special populations (unhoused, agriculture workers & families, veterans).

What are the infrastructure characteristics of your health center (use of expanded care team, culture)?

How do interventions and/or workflows need to be adapted to ensure health equity?

41% of CCHC patients are best served in a language other than English so providing written education materials, videos in other languages are important. In pursuit of health equity, our DEI practices at CCHC focus on meeting each patient where they are so the interventions chosen are to ensure each patient’s understanding related to their specific data.

How complex are the patient interventions to implement (e.g., perceived difficulty of implementation, reflected by duration, scope, radicalness, disruptiveness, and number of steps required)?

Currently, all interventions are done in the exam room (videos) and the ASCVD calculator teaching tool is shown via provider’s iPhone or iPad with the patient.

What are key characteristics of the participating setting(s)?

External Characteristics

What external or environmental supports or threats are there?

Plan

Actual

Describe Intervention

Chosen intervention: YouTube video – getting on iPads or terminals in each exam room for videos only or getting link to patients to watch on smartphones (Spanish and English versions) 

PHAS Year 4 Statin Tool Testing.docx

Plan for intervention: : using the same YouTube video will expand to SpSp version. We will initiate beyond pilot team at Davis site (DCC) to all DCC teams starting Dec 2023 and then all provider teams at the other original CCHC sites by Mar 2024.

Chosen Intervention:

Date when implemented:

Updates: added Spanish video

Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention)

Reach of implementers/providers?

Planned: All Providers, all sites

Reach of implementers/providers?

Actual: have tested with one provider panel as of 2/5, plan to expand to two others

Reach of patients?

Planned: one site 8 to 10 pts a day to start with 

Reach of patients?

Actual: will add numbers after call

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working? ? --Survey for patients – tool influence understanding their risk and willingness to initiate or continue statin RX? 

--Did prescribing increase for patients who received the tool? 

don't know if patient will take Rx or not, conversation around lifestyle and MI style - statin is an option but not always selected by pt, at next visit present numbers again - this has changed because of goals - statin might happen 3rd visit , option for clinician tallying impact of conversation and MA measuring number of patients exposed to the video

Q: tailored strategy for high risk patients (don’t need high risk calculator for them) - A: challenge for patients not on a statin yet is lack of opportunity to provide patient choice

if can capture number of conversations it takes for patients to uptake statins would be very helpful information

Were you able to accurately measure how your intervention was working?

2/5 In December encountered some barriers - wanted an ipad with every panel to show

videos in English and Spanish along with risk calculator - still waiting for ipads, should have them

by next month.

What outcomes do you expect? Increase patient education and engagement. Patients that watch the video will decide to get on a statin. influence understanding their risk and willingness to initiate or continue statin RX

What outcomes have you seen?

Pilot provider reported it was helpful to have app and show the patients and convince

them to try the Rx or be compliant. There was some tracking by medical assistants that might be helpful data.

Spreading to other provider with less well established panels or different routine/ way they get through patient visits

will be interesting to see if the effectiveness holds.

How will you ensure your intervention will be effective for your target population?

Did your intervention reach the target population?

2/5 discussed social needs questions - need for care management but not sure if there is capacity for that

What unintended consequences or outcomes might there be?

What unintended outcomes did you experience?

Adoption (#/% and representativeness of staff and sites who implemented the intervention)

How did clinicians respond to interventions to intensify medication more rapidly/address therapeutic inertia?

Who will deliver the intervention (actually do the work)? Include staff and sites, if applicable.

Medical Assistant/ Provider

Who delivered the intervention? Did they have the skills and time needed to complete the intervention?

2/5 time is a factor - figuring out what to offload from provider or other care team help out

How will you know if clinicians/care teams/sites used the intervention?

provider two-question survey 

What proportion of the planned staff/sites implemented the intervention?

Were there any differences between care teams/sites who adopted the intervention best vs. others who did not (e.g., differences in staff types, capacity, etc.)?

see notes above - in process. Questions were around whether using ASCVD risk tool was working, if it is helpful in reviewing

with patients (simple 2 measure survey). Health Efficient offered to share their questions

Implementation Fidelity (How closely the staff/sites followed the intervention design, delivered it as intended – also called fidelity to the intervention)

How will you know what adaptations or modifications were made during the intervention?

How did you track modifications during the intervention?

What might be some of the possible obstacles to consistent implementation? Capacity, health center merger

What were the barriers to consistent intervention implementation?

What costs and resources (including time and burden, not just money) need to be considered? EHR transition April 2024 Go live but prep will start several months before. Staff Capacity.

What costs and resources (including time and burden, not just money) need to be considered?

How closely did the staff/sites follow the intervention design and deliver as intended?

Check all that apply:

• Followed as designed
• Followed with minor modifications
• Followed somewhat as designed
• Not followed as design
• Delivered consistently/as intended
• Delivered somewhat consistently/somewhat as intended
• Delivered inconsistently/not as intended

Modifications made and other notes:

Maintenance (Extent to which intervention is part of routine practices and protocols)

What reinforcements will you put in place to sustain the intervention, if effective?

• Protocols
• Clinical decision support (alerts, order sets, templates, registries)
• Policies
• Regular training
• Regular reports
• Incentives
• Other:

Explain:

What reinforcements did you put into place to sustain the intervention?

• Protocols
• Clinical decision support (alerts, order sets, templates, registries)
• Policies
• Regular training
• Regular reports
• Incentives
• Other:

Explain:

How will you spread your intervention and lessons learned?

Internal health center meetings. Aliados Health peer network meetings.

How will you spread your intervention and lessons learned?

What are likely modifications or adaptations that will need to be made to sustain the intervention over time (e.g., lower cost, different staff, reduced intensity, different settings)?

Intervention #2

Plan

Intervention #2

Actual

Describe Intervention

Chosen intervention: ASCVD Risk calculator

Plan for intervention: Continue using IPads to expand beyond the pilot team at DCC to all provider teams at DCC by Dec 2023. Starting Mar 2024, we will roll out risk calculator tool (using IPads) to all provider teams at the remaining CCHC sites.

Chosen Intervention:

Date when implemented: not implemented yet, haven’t been able to build it in. Added link of

calculator to iPad to click on videos and clinician use it in internet

Updates: February 2024, Received iPads for all care teams at Davis. Will be targeting interventional education video with all patients.

Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention)

Reach of implementers/providers?

Planned: all sites, working on estimated number, probably more than intervention. 2-4 providers.

Reach of implementers/providers?

Actual:

Reach of patients?

Planned: 6 patients/day average per team

Reach of patients?

Actual:

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working?

number of patients exposed to the risk tool and their understanding, including conversations with provider, what their cardiovascular disease risk means and steps to manage.

Were you able to accurately measure how your intervention was working?

suggestion: did patient receive a statin, but also assess patient decision to go on a statin (video,

calculator or both - sample of patients)

number of conversations to create that change - how do prescribing patterns relate to this

What outcomes do you expect?

• regarding cardiovascular risk, we encourage patient autonomy by choosing their intervention from, (A) physical activity goal, (B) caloric intake goal (C) medication goal

What outcomes have you seen?

the patients have been able to play with the numbers in conjunction with the video, haven’t been able to

patients who are already on the statin affirm that they would like to see if they would like to see additional videos in the future.

Patients not on statin they play video then play with the calculator

How will you ensure your intervention will be effective for your target population?

we believe patient-driven choice/participation will be more motivating to reduce risk than provider-driven.

Did your intervention reach the target population?

What unintended consequences or outcomes might there be?

we are hopeful the patient visit will be motivated to achieve positive change however the strategy chosen maybe something other than a statin.

What unintended outcomes did you experience?

Adoption (#/% and representativeness of staff and sites who implemented the intervention)

How did clinicians respond to interventions to intensify medication more rapidly/address therapeutic inertia?

Who will deliver the intervention (actually do the work)? Include staff and sites, if applicable.

Providers, medical assistants

Who delivered the intervention? Did they have the skills and time needed to complete the intervention?

How will you know if clinicians/care teams/sites used the intervention?

What proportion of the planned staff/sites implemented the intervention?

Were there any differences between care teams/sites who adopted the intervention best vs. others who did not (e.g., differences in staff types, capacity, etc.)?

Implementation Fidelity (How closely the staff/sites followed the intervention design, delivered it as intended – also called fidelity to the intervention)

How will you know what adaptations or modifications were made during the intervention?

How did you track modifications during the intervention?

What might be some of the possible obstacles to consistent implementation?

What were the barriers to consistent intervention implementation?

What costs and resources (including time and burden, not just money) need to be considered?

What costs and resources (including time and burden, not just money) need to be considered?

How closely did the staff/sites follow the intervention design and deliver as intended?

Check all that apply:

• Followed as designed
• Followed with minor modifications
• Followed somewhat as designed
• Not followed as design
• Delivered consistently/as intended
• Delivered somewhat consistently/somewhat as intended
• Delivered inconsistently/not as intended

Modifications made and other notes:

Maintenance (Extent to which intervention is part of routine practices and protocols)

What reinforcements will you put in place to sustain the intervention, if effective?

• Protocols
• Clinical decision support (alerts, order sets, templates, registries)
• Policies
• Regular training
• Regular reports
• Incentives
• Other:

Explain:

What reinforcements did you put into place to sustain the intervention?

• Protocols
• Clinical decision support (alerts, order sets, templates, registries)
• Policies
• Regular training
• Regular reports
• Incentives
• Other:

Explain:

How will you spread your intervention and lessons learned?

How will you spread your intervention and lessons learned?

What are likely modifications or adaptations that will need to be made to sustain the intervention over time (e.g., lower cost, different staff, reduced intensity, different settings)?