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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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Important Health Center Context Fill out this section during your planning process | |
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Internal Characteristics | |
What are the characteristics of your health center? (rural/urban; other demographic variables)? | Urban About 45,000 patients seen in 2022 About 160,000 visits in 2022 · 65.73% = Adults · 25.91% = Children · 8.36% = Seniors (65+) · 68.99% = Need Translation · 79.97% = Income below 200% FPL · 52.22% = Uninsured · 33.11% = Medicaid |
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? | Interventions and workflows are adapted in several ways to ensure health equity in line with Zufall's mission of providing quality, affordable, and culturally responsive healthcare. Firstly, interventions are designed to be inclusive and accessible to all patients, especially those facing barriers to care. This involves considering language needs, cultural sensitivities, and health literacy levels to ensure that information and services are understandable and relevant to diverse patient populations. Additionally, workflows are structured to identify and address disparities in care proactively. This includes using data to pinpoint gaps and tailoring interventions to meet the identified needs. |
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)? | The complexity of implementing patient interventions such as the ones described can be considerable, primarily due to several factors, including perceived difficulty, the extent of planning required, and the need for ongoing adjustments. The interventions are not short-term fixes but require a sustained effort over a considerable period. They encompass a broad scope, targeting specific patient groups with tailored approaches, which adds to their complexity. Introducing new processes can be seen as radical changes to existing practices. While they aim to improve patient outcomes, they might initially disrupt established workflows. This necessitates careful management to ensure smooth integration into daily routines. The interventions involve multiple steps – each step requires meticulous attention and coordination. Implementing these interventions requires thorough planning and the identification of champions – individuals who advocate for and lead the execution of these initiatives. Champions play a crucial role in driving the intervention, gaining buy-in from other staff, and guiding the project towards its objectives. Typically, interventions at Zufall start on a smaller scale to test their effectiveness. Scaling them up to the entire center requires obtaining buy-in from providers, which can be a challenging process. Ensuring providers understand and support the intervention's goals is critical for success. Ongoing education and providing necessary tools are vital to keep staff updated and equipped to carry out the interventions effectively. This requires regular organization and resource allocation. Continuous feedback from staff is essential to minimize workflow disruption and enhance effectiveness. This feedback must be used to make timely modifications to any intervention, ensuring it aligns well with existing practices while achieving its intended goals. Given these factors, it's clear that while these patient interventions hold significant potential for improving patient outcomes, their implementation is complex and demands careful management, continuous support, and adaptability. |
What are key characteristics of the participating setting(s)? | · 7 clinical sites · >30 providers · >4,000 patients in Statin cohort |
External Characteristics | |
What external or environmental supports or threats are there? | N/A |
Plan | Actual |
Describe Intervention Chosen intervention: Patient focused, targeting LDLs >190 not on Statin Plan for intervention: The first intervention is a comprehensive, two-part strategy aimed at enhancing clinical practice and patient outcomes. It begins with distributing a 'Clinical Pearl' newsletter to our staff, providing valuable insights and the latest updates in the medical field. The first issue focused on Familial Hypercholesterolemia, the implications of high LDL levels, and the utilization of statins in treatment. This initiative serves not only as an educational tool but also as a catalyst for proactive patient care. Following the newsletter, each healthcare provider received a tailored list of their patients exhibiting LDL levels above 190 who were not currently prescribed statins. This actionable list enables providers to engage in direct follow-up with these patients, ensuring personalized care. Providers are tasked with either initiating a statin treatment plan or updating patient records to reflect any contraindications or refusals regarding statin therapy. This two-pronged approach is designed to foster both knowledge enhancement and active patient management, ultimately aiming to improve health outcomes. | Chosen Intervention: Date when implemented: October 16, 2023 Updates: Had some providers find it helpful. Feedback included improving ways to communicate the data to the providers to take appropriate actions when necessary. Providers assist in identifying why some patients are not on statins, and use that for education on utilizing appropriate ICD codes to generate more accurate reports. Testing messages on elevated LDLs with patients and providers (through CDC grant)-do not have ability to send message through Labcorp, but are manually sending messages. Places message in the lab notes if provider has not yet communicated with the patient. Also noting what the providers are doing when they’ve reached out to patients already and what actions they’ve taken (tracking on spreadsheet). Most times providers have taken action and have prescribed statins. Intervention has been successful, and find that providers are proactive. Providers are being proactive with placing patients on statins. |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: 35 | Reach of implementers/providers? Actual: 35-sent data to all providers in October. Dr. Ramirez reaching out to providers individually. |
Reach of patients? Planned: 100 | Reach of patients? Actual: working towards goal LDL messaging project using direct messaging: 104 patients (since December 2023) |
Efficacy (Impact of intervention on important outcomes) | |
How will you measure that your intervention is working? Tracking the number of patients initiating statin therapy following the intervention, alongside monitoring key health indicators such as changes in LDL levels. In addition, provider feedback will be gathered and assessed to see if this intervention is effective and to understand some barriers or scenarios encountered that affect statin uptake with patients. Compliance and follow-up rates will also be tracked, examining the proportion of providers who engage in patient follow-ups post-list receipt and the frequency of patient chart updates with either new statin prescriptions or documented reasons for non-prescription. An integral part of this strategy includes generating reports to track if patients scheduled appointments post-outreach and received statin prescriptions | Were you able to accurately measure how your intervention was working? Generates report and compares to previous reports. Received provider feedback and also performs observations. Providers proactive. Providers are utilizing the ASCVD risk scores and also utilizing models of arteries with patients (helpful during telehealth visits). Rates increasing in this group (74% to 75%). Difficult to move the needle in population, but are seeing increases across all risk groups. Through performing individual provider chart reviews, seeing increase in providers f/u with patients regarding labwork, prescriptions, and continuing conversations regarding statin therapy. |
What outcomes do you expect? Increased prescription rates of statins among eligible patients. Improved control of LDL levels in patients. Enhanced provider awareness and knowledge about the importance of statin use in these specific patient populations. | What outcomes have you seen? Providers are proactive in prescribing statins. Providers are understanding the guidelines (practice-based & knowledge-based transformations occurring). Rates increasing in this group (74% to 75%). Difficult to move the needle in population, but are seeing increases across all risk groups. Through performing individual provider chart reviews, seeing increase in providers f/u with patients regarding labwork, prescriptions, and continuing conversations regarding statin therapy. Chart reviews allows dialogue with providers regarding changes in behaviors. Personalized discussion with providers regarding specific cases, allowing teaching moments regarding patient treatment/tools/talking points to addressing patient-related barriers. Also, how to help providers with motivational interviewing techniques. Also, through chart reviews, when pt refusals are noted, able to send notes to providers to try different methods. Have full transparency with project. |
How will you ensure your intervention will be effective for your target population? Offer additional training or support to providers to help them effectively use the information and tools provided. Include strategies to educate and engage patients about the importance of statin therapy, addressing any concerns or misconceptions. For example, having artery models at each site available to help inform and demonstrate to the patients the effects plaque can have and what a statin can help do. | Did your intervention reach the target population? Yes. Providers are addressing pts with elevated LDLs/Smokers/High Risk populations (ASCVD, DM, ASCVD >7.5 or 10) |
What unintended consequences or outcomes might there be? There are no unintended consequences or outcomes. | What unintended outcomes did you experience? Intervention has been positive. There is a sense of urgency when seeing the elevated LDLs. Continues to be well received by providers and patients. |
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 at all the sites. The report is generated by the data analyst and reviewed by the QA Program Manager and CMO. The Clinical Pearl is developed in collaboration with the CMO and QA Program Manager. Each provider will reach out to the patients for follow up or update the patient’s charts. | Who delivered the intervention? Did they have the skills and time needed to complete the intervention? Providers, VP of PI, CMO At points the providers will have conversations with the Clinical Pharmacist. |
How will you know if clinicians/care teams/sites used the intervention? Through data reports that will see if there was change between the original list and the new lists. In addition, providers will communicate any issues or updates. | What proportion of the planned staff/sites implemented the intervention? across all sites. 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.)? Some providers continue to need reinforcement of education, other providers understand the guidelines. Have 1 or 2 outliers |
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? Reports will be used as a tool to measure if the process is being adhered to or if the process is improving statin rates. In addition, discussions with providers and how they approach patients regarding statins are very valuable. Providers provide feedback and share success stories during Clinical and QA/PI Meetings, which assists in replicating these strategies at other sites. | How did you track modifications during the intervention? Reports monthly to track interventions. Utilizing feedback from providers. Maintain a spreadsheet. Individual provider chart reviews. |
What might be some of the possible obstacles to consistent implementation? Some possible obstacles include misunderstanding of the intervention, high workloads, staff shortages, time constraints that might lead to omissions, variability in patient responses and compliance, and limited resources. | What were the barriers to consistent intervention implementation? Hesitancy/lack of an explanation of the project/taking into account the providers time (addressing statins during sick visits). New providers in trainings-educating on protocols. Change Healthcare cyberattack affecting prescriptions being received by pharmacies. |
What costs and resources (including time and burden, not just money) need to be considered? Time required for staff training/discussions, data entry, patient follow-ups, and overall intervention process management. The additional workload can lead to staff burden and resources for ongoing monitoring, evaluation, and possible modifications to the intervention based on feedback and reports. | What costs and resources (including time and burden, not just money) need to be considered? Available time among staff/providers to review reports. CMOs time in reviewing reports and meeting with providers. Funds for educational tools/resources. |
How closely did the staff/sites follow the intervention design and deliver as intended? Check all that apply:
Modifications made and other notes: Make modifications based on individual patients. Have residents in sites/educate residents and preceptors. | |
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?
Explain: Zufall is a data-driven organization. The reports will be used to continue to assist care teams with targeted interventions and increase statin rates at their sites. | What reinforcements did you put into place to sustain the intervention?
Explain: Policies follow guidelines. Recognize providers at meetings who are showing success. In general, recognize high achievers. |
How will you spread your intervention and lessons learned? If the intervention proves to be successful, the strategy for disseminating the intervention and lessons learned will be centered around ongoing education and sharing comprehensive reports with all relevant teams. This approach aims to continue increasing the rates of effective statin therapy among the targeted patient populations. Regular education sessions will be organized to keep all staff members up-to-date. Detailed reports will be distributed across teams. These reports will serve as valuable resources for understanding the intervention's impact and replicating its success. The goal is to create a feedback loop where the achievements and learnings continuously inform and improve practice across Zufall and overall increase statin rates. | How will you spread your intervention and lessons learned? Continuing regular trainings/education, meeting 1:1 with providers. |
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)? N/A Statin Champions to reinforce at their locations/sites. | |
Intervention #2 Plan | Intervention #2 Actual |
Describe Intervention Chosen intervention: Patient focused, targeting those with Diabetes, not on Statins Plan for intervention: The second intervention mirrors the structure of the first, yet it explicitly targets a different patient demographic: individuals with diabetes who are not currently prescribed statins. This initiative begins similarly with distributing a tailored 'Clinical Pearl' newsletter, focusing on the critical intersection of diabetes management and statin therapy. Then each provider receives a list of their diabetic patients not on statin therapy. Providers are encouraged to assess the suitability of statin therapy for these patients, considering their overall health profile and diabetes management plan. The goal is to initiate statin therapy where appropriate or to document specific reasons for its exclusion, such as contraindications or patient refusal. | Chosen Intervention: Clinical Pharmacist led intervention, Patient focused, targeting those with Diabetes, not on Statins The second intervention aims to enhance statin utilization among patients with diabetes who are not currently prescribed statins. The strategy involves a detailed report to pinpoint patients not taking statins. Following this, Zufall's Clinical Pharmacist will thoroughly review each identified patient's record. The Clinical Pharmacist will assess the suitability of statin therapy for these patients, considering their overall health profile and diabetes management plan. These patients will then be integrated into Zufall's diabetes program and receive comprehensive Diabetes Self-Management Education and Support (DSMES) from the Clinical Pharmacist. This initiative focuses on educating patients about medication adherence and emphasizes building a strong rapport with the patient that will impact statin initiation. The ultimate goal is to encourage and facilitate the initiation of statin therapy for these patients. Date when implemented: Updates: |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: 1 clinical pharmacist; will review report to identify how many providers he communicated with. | Reach of implementers/providers? Actual: |
Reach of patients? Planned: 500 patients on report | Reach of patients? Actual: Sent 547 to clinical pharmacist for review.234records were reviewed. |
Efficacy (Impact of intervention on important outcomes) | |
How will you measure that your intervention is working? Tracking the number of patients initiating statin therapy following the intervention, alongside monitoring key health indicators such as changes in LDL levels. In addition, provider feedback will be gathered and assessed to see if this intervention is effective and to understand some barriers or scenarios encountered that affect statin uptake with patients. Compliance and follow-up rates will also be tracked, examining the proportion of providers who engage in patient follow-ups post-list receipt and the frequency of patient chart updates with either new statin prescriptions or documented reasons for non-prescription. An integral part of this strategy includes generating reports to track if patients scheduled appointments post-outreach and received statin prescriptions. Tracking the number of patients initiating statin therapy following the intervention, alongside monitoring key health indicators such as changes in LDL levels. In addition, feedback from the Clinical Pharmacist will be gathered and assessed to see if this intervention is effective and to understand some barriers or scenarios encountered that affect statin uptake with patients. Compliance and follow-up rates will also be tracked, examining the frequency of patient chart updates with new statin prescriptions. An integral part of this strategy includes generating reports to track if patients scheduled appointments post-outreach with the Clinical Pharmacist and received statin prescriptions. | Were you able to accurately measure how your intervention was working? Clinical pharmacist sent telephone encounters to providers with recommendations. Noted most providers were receptive to feedback. Would also notify providers if a patient was not adherent and have providers f/u with patient. Also, making recommendations to providers based on patient-specific scenarios. |
What outcomes do you expect? Increased prescription rates of statins among eligible patients. Improved control of LDL levels in patients. Enhanced provider awareness and knowledge about the importance of statin use in these specific patient populations. Increased prescription rates of statins among eligible patients. Improved control of LDL levels in patients. | What outcomes have you seen? Noted one provider was not as receptive to feedback regarding statin recommendations. This intervention was helpful in keeping patients engaged in care, and also getting patients back in for f/u care. |
How will you ensure your intervention will be effective for your target population? Offer additional training or support to providers to help them effectively use the information and tools provided. Include strategies to educate and engage patients about the importance of statin therapy, addressing any concerns or misconceptions. For example, having artery models at each site available to help inform and demonstrate to the patients the effects plaque can have and what a statin can help do. Personalized DSMES education will meet the individual needs and preferences of each patient. This includes language preferences, cultural considerations, and addressing specific barriers to medication adherence. A follow-up system should be established to monitor patient progress, statin therapy adherence, and any health status changes. Regular check-ins by the clinical pharmacist will help adjust the intervention as needed and address any emerging issues promptly. Ensuring the intervention is seamlessly integrated into the patient's current healthcare routines. This includes coordination with the PCPs involved in the patient's care to provide a unified approach. Include strategies to educate and engage patients about the importance of statin therapy, addressing any concerns or misconceptions. | Did your intervention reach the target population? Intervention reached the target population. Report to be validated to ensure all patients on the report fit the criteria. |
What unintended consequences or outcomes might there be? There are no unintended consequences or outcomes. | 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 at all the sites. The report is generated by the data analyst and reviewed by the QA Program Manager and CMO. The Clinical Pearl is developed in collaboration with the CMO and QA Program Manager. Each provider will reach out to the patients for follow up or update the patient’s charts. The Clinical Pharmacist will be directly delivering the intervention. The report is generated by the data analyst and reviewed by the QA Program Manager and CMO. | Who delivered the intervention? Did they have the skills and time needed to complete the intervention? Clinical pharmacist delivered the intervention across all sites/providers. QA Program Manager (VP of QA & Clinical Risk Management) and CMO continue to collaborate on intervention. |
How will you know if clinicians/care teams/sites used the intervention? Through data reports that will see if there was change between the original list and the new lists. In addition, providers will communicate any issues or updates. Through data reports that will see if there was change between the original list and the new lists. In addition, the Clinical Pharmacist will communicate any issues or updates. | What proportion of the planned staff/sites implemented the intervention? Intervention implemented across all sites/all providers with the clinical pharmacist performing the review. 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.)? There were providers who reacted immediately upon receiving recommendations, while others discussed the recommendations with patients first before implementing. Also, had 1 provider who was not as receptive to recommendations. |
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? Reports will be used as a tool to measure if the process is being adhered to or if the process is improving statin rates. In addition, discussions with providers and how they approach patients regarding statins are very valuable. Providers provide feedback and share success stories during Clinical and QA/PI Meetings, which assists in replicating these strategies at other sites. Reports will be used as a tool to measure if the process is being adhered to or if the process is improving statin rates. In addition, discussions with the Clinical Pharmacist and how they approach patients regarding statins are very valuable. They will provide feedback and share success stories, which assists in replicating these strategies at other sites. | How did you track modifications during the intervention? Utilizing the report to track modifications, also frequent discussion with clinical pharmacist on intervention. Also obtain feedback from providers regarding efficacy of the intervention. |
What might be some of the possible obstacles to consistent implementation? Some possible obstacles include misunderstanding of the intervention, high workloads, staff shortages, time constraints that might lead to omissions, variability in patient responses and compliance, and limited resources. Some possible obstacles include misunderstanding of the intervention, high workloads, staff shortages, time constraints that might lead to omissions, variability in patient responses and compliance, and limited resources. | What were the barriers to consistent intervention implementation? It was noted the report contains patients who do not have a diagnosis of Diabetes, will need to verify accuracy of reports. |
What costs and resources (including time and burden, not just money) need to be considered? Time required for staff training/discussions, data entry, patient follow-ups, and overall intervention process management. The additional workload can lead to staff burden and resources for ongoing monitoring, evaluation, and possible modifications to the intervention based on feedback and reports. Time required for staff training/discussions, data entry, patient follow-ups, and overall intervention process management. The additional workload can lead to staff burden and resources for ongoing monitoring, evaluation, and possible modifications to the intervention based on feedback and reports. | What costs and resources (including time and burden, not just money) need to be considered? Time: requires time to review reports/make recommendations among other day-to-day duties. |
How closely did the staff/sites follow the intervention design and deliver as intended? Check all that apply:
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?
Explain: Review reports during monthly QA meetings. Reinforce current protocols in place. Provider reminders to providers and provide tailored reminders to the providers to review charts. | What reinforcements did you put into place to sustain the intervention?
Explain: Providing educational updates to providers during each clinical meeting. Still utilizing reports and reinforcing current protocols. |
How will you spread your intervention and lessons learned? If the intervention proves to be successful, the strategy for disseminating the intervention and lessons learned will be centered around ongoing education and sharing comprehensive reports with all relevant teams. This approach aims to continue increasing the rates of effective statin therapy among the targeted patient populations. Regular education sessions will be organized to keep all staff members up-to-date. Detailed reports will be distributed across teams. These reports will serve as valuable resources for understanding the intervention's impact and replicating its success. The goal is to create a feedback loop where the achievements and learnings continuously inform and improve practice across Zufall and overall increase statin rates. If the intervention proves to be successful, the strategy for disseminating the intervention and lessons learned will be centered around ongoing education and sharing comprehensive reports with all relevant teams. This approach aims to continue increasing the rates of effective statin therapy among the targeted patient populations. Regular education sessions will be organized to keep all staff members up-to-date. Detailed reports will be distributed across teams. These reports will serve as valuable resources for understanding the intervention's impact and replicating its success. The goal is to create a feedback loop where the achievements and learnings continuously inform and improve practice across Zufall and overall increase statin rates. | How will you spread your intervention and lessons learned? The intervention is worthwhile doing, plan to continue utilizing this intervention. Clinical pharmacist also has clinical pharmacy students to assist with intervention-if relationship with pharmacy school remains, this intervention could be sustainable. In the future would like to see policy changes to the amount of autonomy the clinical pharmacist’s scope to make changes/prescribe statin medications without the need to go through the extra layer of the provider. |
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)? Clinical pharmacist also has clinical pharmacy students to assist with intervention-if relationship with pharmacy school remains, this intervention could be sustainable. | |
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