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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

  • 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 mentos

  • 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:

Plan for intervention:

Chosen Intervention:

Date when implemented:

Updates:

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

Reach of implementers/providers?

Planned:

Reach of implementers/providers?

Actual:

Reach of patients?

Planned:

Reach of patients?

Actual:

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working?

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

What outcomes do you expect?

What outcomes have you seen?

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

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?

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:

Chosen Intervention:

Date when implemented:

Updates:

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

Reach of implementers/providers?

Planned:

Reach of implementers/providers?

Actual:

Reach of patients?

Planned:

Reach of patients?

Actual:

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working?

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

What outcomes do you expect?

What outcomes have you seen?

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

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?

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)?



Version Date Comment
Current Version (v. 5) Oct 28, 2023 00:05 Antoinette Anwar
v. 21 Apr 18, 2024 18:00 Antoinette Anwar
v. 20 Apr 18, 2024 17:27 Antoinette Anwar
v. 19 Apr 16, 2024 13:24 Antoinette Anwar
v. 18 Apr 16, 2024 13:18 Antoinette Anwar
v. 17 Apr 15, 2024 21:28 Antoinette Anwar
v. 16 Apr 15, 2024 21:25 Antoinette Anwar
v. 15 Apr 15, 2024 18:31 Antoinette Anwar
v. 14 Feb 27, 2024 18:52 Chris Espersen
v. 13 Feb 27, 2024 14:40 Antoinette Anwar
v. 12 Jan 11, 2024 16:10 Antoinette Anwar
v. 11 Jan 05, 2024 18:38 Lauren Becker
v. 10 Dec 21, 2023 15:21 Antoinette Anwar
v. 9 Dec 06, 2023 18:43 Chris Espersen
v. 8 Dec 06, 2023 14:37 Antoinette Anwar
v. 7 Dec 06, 2023 14:31 Antoinette Anwar
v. 6 Nov 08, 2023 13:59 Antoinette Anwar
v. 5 Oct 28, 2023 00:05 Antoinette Anwar
v. 4 Oct 24, 2023 18:38 Antoinette Anwar
v. 3 Oct 24, 2023 18:09 Antoinette Anwar
v. 2 Oct 13, 2023 18:40 Lauren Becker
v. 1 Sept 18, 2023 20:31 Lauren Becker
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