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

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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

  • Approx. 43,000 patients

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

  • Care team: provider, specialty providers – optometry, BH, nutrition, podiatry, nursing staff, managed care

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

  • closed loop referral system such as Unite Us to address social determinants of health

  • continuation of telehealth and remote patient monitoring

  • additional case managers

  • health educator, facilitator, or navigator

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)?

  • Many interventions are needed to make sure these translate into meaningful patient outcomes:

  • Patient needs and resources need to be not only identified but addressed; culture must also be taken into consideration

  • Leadership/admin involvement must be included

  • Effective evaluation plans are also needed

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

  • Involved care teams

  • Nursing and medical work well together

  • Strong outreach services

  • Auspices of diabetic peer mentosmentors

  • Utilization of APRN as team lead for HTN and DM groups

  • Managed care input; interdisciplinary team meetings

External Characteristics

What external or environmental supports or threats are there?

  • Strengths

    • Engaged patient population

    • Strong community partners – HCN, AHA, Unite Us

  • Threats

    • Adverse social determinants of health

      • Access to needs

Plan

Actual

Describe Intervention

Chosen intervention: Statin Initiation and Follow Up

Plan for intervention:a.

  1. Initiate Statin therapy for high-risk patients not currently on statin therapy during telemedicine and office visit encounters.

b.

  1. Schedule 3 month follow up to assess response to therapy to include labs or point of care device. Review prescriptions.

c.

  1. Part of encounter activity, engaging with provider and patients during visit, recommending statin.

  2. Monthly group meeting opportunity

Chosen Intervention: Statin Initiation, Follow Up, and Maintenance

Date when implemented: 7/1/23

Updates:

#1 Dec 2023 -

  • found that patients were not always able to come into clinic to be assessed for statin therapy - can assess in other ways. Decided the providers/MAS partnered to determine which patients missed or did not come into appt. Reached out via telemedicine- extremely successful.

  • Leon took time daily to provide with guidelines - whenever working in clinic will review patient population and ask if they could benefit from statin therapy and then see if MA could recall pt.

  • Statin therapy assessment - ensuring pts don't fall through the cracks if no one follows up.

#2 Feb 2024 -

  • Leon reviewed list and there was a gap in the process, Leon would call - have great relationships with providers

  • can see actual appointments in chart

  • ensuring they are recommending statin therapy. Many times patient who providers consider well managed (A1c). Have an opportunity for provider to work directly with patients

Questions for Poster for Harvest Meeting:

  • Strategy Name (e.g., outreach, clinical decision support, clinician education, data reports, etc.)

  • Strategy Description 

  • Who Enacts the Strategy? (e.g., QI staff, clinicians, health center leadership, patients/consumers, etc.)

  • What specific Actions, Steps, or Processes Need to be Enacted?

  • When is the Strategy Used? (e.g., during each patient visit, during monthly QI meetings)

  • What is the Dose of the Strategy? (e.g., one 3-hour training)

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

Reach of implementers/providers?

Planned:

  • 3 providers

    • Dr. Francois

    • Dr. Jackson

    • Dr. Silvera’s MA

Reach of implementers/providers?

Actual:

  • 5: Dr. Williams, Dr. Francois and Dr. Cordone were part of the intervention. Other providers like Dr. Jackson and Dr. Sylvera also participated.

  • However, Dr. Williams, Dr. Cordone and Dr. Francois saw the highest number of patients for therapy.

Reach of patients?

Planned:

  • all cohort patients

Reach of patients?

Actual:

  • at least 60% of patients were contacted in some way

  • statin initiation # pending completion of MH Y6 data workbook

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working?

  • Monitor Statin UDS performance and Data Workbook

  • May also want to look at outreach attempts and success

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

  • Yes, using Epic reports to monitor cohort f/us and rx

What outcomes do you expect?

  • increased performance in both of above

What outcomes have you seen?

  • biggest increase in diabetes cohort performance

  • slight increase in LDL & ASCVD cohorts

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

  • Observe reduction in ASCVD Risk scores and LDL

Did your intervention reach the target population?

  • Yes

What unintended consequences or outcomes might there be?

What unintended outcomes did you experience?

  • Leaning on telehealth for good portion of patients for conversation on statin initiation or the f/u portion.

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.

  • all family practice providers and self

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

  • 5 providers + Dr. Lawrence, Leon Bain. Yes.

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

  • use Million Hearts report to monitor follow up visit dates

  • Track patient follow up in EPIC.

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

  • 6/8 + Leon Bain

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 provider performance in intervention 2.

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?

Patients are being tracked using spreadsheet/log

How did you track modifications during the intervention?

  • spreadsheet/log to track statin initiation

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

What were the barriers to consistent intervention implementation?

  • provider/patient hesitancy

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

Providing consistent information to patients. Flyers, handouts etc. Design and implementation

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

  • Time, staff resources

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: action plan

Explain:

How will you spread your intervention and lessons learned?

During provider and/or staff meetings

How will you spread your intervention and lessons learned?

  • Communicate electronically to expand reach

  • Focus on sites & providers that aren’t performing as well

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)?

  • Encouraging use of statin tools differently to drive use. Maybe consider incentives or monthly tracking.

  • Random site visits and electronic communication

  • Provider education on referrals during provider meetings

  • Action plans for providers

Intervention #2

Plan

Intervention #2

Actual

Describe Intervention

Chosen intervention: Patient Outreach

Plan for intervention:a.

  1. Use alternative information sources like text and outreach calls to remind patients of Friday meetings (education

and treatment for at risk patients

  1. /statin tool and activities).

b.

  1. Provide appointments for those patients who respond to outreach activity

.
c. Clinical references: statin tools (Q&A)

Chosen Intervention: Patient Outreach

Date when implemented: January 2024

Updates:

  • Groups dedicated to patients living with diabetes 1x/month

  • Clinic visits dedicated to statin/hypertension 10-12 patients every Friday

  • Questions for Poster for Harvest Meeting:

    • Strategy Name (e.g., outreach, clinical decision support, clinician education, data reports, etc.) - statin initiation for high risk patients

    • Strategy Description 

    • Who Enacts the Strategy? (e.g., QI staff, clinicians, health center leadership, patients/consumers, etc.) : Leon, MAs, Dr. Francois, dietician, Dr. Lawrence

    • What specific Actions, Steps, or Processes Need to be Enacted?

      • Generate report - monthly-> increased weekly

      • Sort by risk scores and provider

      • Shared with providers in person, will be sharing now during provider meeting and electronically as frequently as possible

      • Leon makes calls to patients and schedules a visit/Friday group session, identifies SDOH (group in morning, regular visits during afternoon)

      • Dr. Francois reviews patients at risk

      • Patients come in on Fridays (see above) - education + patients have what need

      • Share with MAs how to follow up with patients - make sure they got Rx filled and have a f/u appointment

      • Look at how to fill in gaps (i.e., Rx not filled)

    • When is the Strategy Used? (e.g., during each patient visit, during monthly QI meetings) Friday group visits

    • What is the Dose of the Strategy? (e.g., one 3-hour training) group visits = 10-12 minutes, regular visits 15-20 minutes, if there are concerns patient is pulled to the side and review Rx, look for and address challenges

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

Reach of implementers/providers?

Planned:

Reach of implementers/providers?

Actual: Leon Bain, Darline Francois

Reach of patients?

Planned:

currently pulling reports in Epic to determine the n (TBD, possibly at the end of the week)

Reach of patients?

Actual: calling 40 patients/week, seeing 10-12 patients every Friday w/Dr. Francois, and various amounts during the week.

Total number (num/demon) =

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working?

  • Run reports on use of statin tools and if/when statin was prescribed (sorted by provider)

  • whether patients came in for the visit

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

  • Yes, used MH reports and ASCVD risk to call patients and track next steps.

  • Leon has other metrics to add

What outcomes do you expect?

  • increase Statin UDS performance and Data Workbook

What outcomes have you seen?

  • So far, 39/50 patients called from MH cohorts are now on statin; the rest are scheduled for a f/u in next 30-60 days.

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

Did your intervention reach the target population?

  • Yes, seeing increase in diabetes cohort performance

What unintended consequences or outcomes might there be?

What unintended outcomes did you experience?

  • Gained a better understanding of how to communicate with patients to drive results (action planning with each provider).

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.

Provider
MA will schedule patients
CHW, DPP will contact patient providers and MA’s to ensure consistent execution

right now, 4 MAs, Leon and 3 providers to start

goal is to have a solid plan and SOP by the end of March

have seen success with the overall diabetes process that are looking at risk score and bringing as part of the group and so even those who are not part of the initial group of 8, patients will be impacted/called

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

  • 4 MAs, Leon and 3 providers; Yes

  • this allows us to reach patients with greatest risks

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

CHW, DPP will conduct on site visits and chart reviews
CHW, DPP will also pull reports by provider to determine if interventions are consistent

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

  • CHW conducts site visits & inspects clinican/MA process

  • CHW checks charts post-encounter

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.)?

  • CHW working primarily with below sites and providers. Those who work closest with CHW have some of highest performance scores in patient panel. Statin Therapy performance with their patient panel as of 4/15/24:

    • Fatima Zafar:

      • Dr. Williams: 87.2% (4/15/24), 76.9% (12/31/23)

      • Dr. Silvera: 71.3% (4/15/24), 71.2% (12/31/23)

      • Dr. Grant (occasionally): 62.2% (4/15/24), 69.2% (12/31/23)

    • Wilson Mann:

      • Dr. Francois: 89% (4/15/24), 85.9% (12/31/23)

    • Miami Gardens:

      • Dr. Cordon: 87.7% (4/15/24), 82.8% (12/31/23)

    • North Shore (occasionally):

      • Dr. Cumberbatch: 66.9% (4/15/24), 74.4% (12/31/23)

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?

will be creating an SOP

are going back to look at the process and reports to see if is occurring as intended, having discussions with staff to check in - trust and respect have been built to have these conversations

How did you track modifications during the intervention?

Action plan with each provider to set tangible, attainable goals pertaining to heart health.

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

Training may present an obstacle; however, staff meetings may mitigate this challenge

What were the barriers to consistent intervention implementation?

Only one CHW, unable to reach every site so will be evolving communication methods to be more electronic

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?

Time, staff

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: action planning

Explain:

How will you spread your intervention and lessons learned?

How will you spread your intervention and lessons learned?

  • Communicate electronically to expand reach

  • Focus on sites & providers that aren’t performing as well

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)?

  • Encouraging use of statin tools differently to drive use. Maybe consider incentives or monthly tracking.

  • Random site visits and electronic communication

  • Provider education on referrals during provider meetings

  • Action plans for providers

...

Change History