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Instructions: Use the pencil icon in the top right to edit the form below. ↗️ Remember to push PUBLISH when you are done to save your work.

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Statin Initiation Goals: PENDING CONFIRMATION

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

  • 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)

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