Broward Community Health Intervention Assessment

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Statin Initiation Goals: PENDING CONFIRMATION

Received Prescription - ASCVD (Cohort): goal of XXX of those who come in for a f/u visit
Received Prescription - LDL ≥190 mg/DL (Cohort): goal of XXX of those who come in for a f/u visit
Received Prescription - Diabetes and LDL 70-189 mg/DL (Cohort): goal of XXX of those who come in for a f/u visit

Important Health Center Context Fill out this section during your planning process
Internal Characteristics
What are the characteristics of your health center? (rural/urban; other demographic variables, use of expanded care team, culture)?	Urban location Demographics: 76% non-Hispanic, 23% Hispanic 65% black/African American, 31% white
What are the infrastructure characteristics of your health center (use of expanded care team, culture)?	Use of expanded care team: Primary Care and specialties such as nutrition, BH, Dental, Peds, OBGYN Culture: mostly afro-Caribbean/black African American
How do interventions and/or workflows need to be adapted to ensure health equity?	Bridge to Wellness: program to address SDOH primarily transportation and food insecurity Participate in MH, TargetBP to address chronic disease conditions Patient care navigators (pre-visit planning, care gaps) Integrated BH team HCT team to address HIV diagnosed pts and HIV prevention Utilization of telehealth to deliver services Managed care department to review care gaps for HEDIS measures QI department reviews UDS performance and takes action monthly (PDSAs)
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)?	Complexities are centered around time and other resources: demand on provider time to address & implement availability of support staff and other resources to operationalize interventions and evaluate outcomes
What are key characteristics of the participating setting(s)?	Strong and engaged Clinical Director of Medical Services Ongoing training and competency evaluation of clinical support staff Open forum via Breakfast Club twice monthly to address provider & clinical support staff learning needs Support of PCN team for pre-visit planning Clinical decision support in Epic EHR (Care Gaps)
External Characteristics
What external or environmental supports or threats are there?	Supports: availability of grant funding for primary health care strong community partnerships strong partnerships with professional organizations (ex: AHA) Threats: funding (Medicaid expansion in FL was declined) Medicaid Redetermination impacts the patient demographic we serve National data reports that most FQHC patients only come for one visit and then switch orgs (BCOM finds this too)

Plan

Actual

Describe Intervention

Chosen intervention:

Plan for intervention:

Ongoing provider education on cholesterol guidelines & strategies to overcome patient hesitancy (motivational interviewing), fine tuning the way we share information and improvement efforts with providers (newsletter).

Each meeting a topic is selected - an issue is the amount of time to explore any topic - each month run providers list of patients who should be on statin therapy and sort by outcome (those not on statin and should be are at top of list.

Chosen Intervention:

Date when implemented:

Updates:

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

Reach of implementers/providers?

Planned: 100% of PCPs will receive education on cholesterol guidelines & strategies to overcome patient hesitancy

Reach of implementers/providers?

Actual:

Reach of patients? 50% of patients at high risk for a cardiovascular event will receive education using a validated clinical reference tool.

Reach of patients?

Actual:

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working?

Epic UDS data for statin therapy

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

What outcomes do you expect?

82% of patients at high risk for a cardiovascular event will be prescribed a statin.

What outcomes have you seen?

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

Monthly data analysis

Did your intervention reach the target population?

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.

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?

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)?

Intervention #2

Plan

Intervention #2

Actual

Describe Intervention

Chosen intervention:

Plan for intervention:

Lists generated. Providers review list and f/u with patients.) Might add staff to add with measures - now that can look at care gaps and quality measures - that extra person could help the providers. In UDS system - BCOM small and Portia is in UDS.) Some inertia. Still recognize the provider heart health champion - this is motivating providers to look at all heart health measures - riding on interest that created this summer)

Wave in Epic - also happening at network level

could do a in person or virtual visit

Chosen Intervention:

Date when implemented:

Updates:

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

Reach of implementers/providers?

Planned: