Jessie Trice Intervention Assessment

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Statin Initiation Goals:

Received Prescription - ASCVD (Cohort): goal of 40% of those who come in for a f/u visit
Received Prescription - LDL ≥190 mg/DL (Cohort): goal of 30% of those who come in for a f/u visit
Received Prescription - Diabetes and LDL 70-189 mg/DL (Cohort): goal of 45% 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)?	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 mentors 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:

Initiate Statin therapy for high-risk patients not currently on statin therapy during telemedicine and office visit encounters.
Schedule 3 month follow up to assess response to therapy to include labs or point of care device. Review prescriptions.
Part of encounter activity, engaging with provider and patients during visit, recommending statin.

Chosen Intervention:

Date when implemented:

Updates: 1. 12/6 - 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 dont fall through the cracks if no one follows up. if

#2 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

#3 see above - 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

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:

Reach of patients?

Planned:

all cohort patients

Reach of patients?

Actual:

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?

What outcomes do you expect?

increased performance in both of above

What outcomes have you seen?

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?

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.

all family practice providers and self

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?

use Million Hearts report to monitor follow up visit dates

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: Patient Outreach

Plan for intervention:

Use alternative information sources like text and outreach calls to remind patients of education and treatment for at risk patients.
Provide appointments for those patients who respond to outreach activity.
Clinical references: statin tools (Q&A)

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?

Run reports on use of statin tools and if/when statin was prescribed

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

What outcomes do you expect?

increase Statin UDS performance and Data Workbook