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.
Statin Initiation Goals:
Received Prescription - ASCVD (Cohort): goal of 20% of those who come in for a f/u visit
Received Prescription - LDL ≥190 mg/DL (Cohort): goal of 25% of those who come in for a f/u visit
Received Prescription - Diabetes and LDL 70-189 mg/DL (Cohort): goal of 50% 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, use of expanded care team, culture)? |
|
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? |
|
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)? |
|
What are key characteristics of the participating setting(s)? |
|
External Characteristics | |
What external or environmental supports or threats are there? |
|
Plan | Actual |
Describe Intervention Chosen intervention: Provider Professional Development Plan for intervention:
| Chosen Intervention: Provider Professional Development
|
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: 100% of PCPs will receive education on cholesterol guidelines & strategies to overcome patient hesitancy | Reach of implementers/providers? Actual: 11 PCPs (100%) |
Reach of patients: 50% of patients at high risk for a cardiovascular event will receive education using a validated clinical reference tool. | Reach of patients? Actual: 84% rolling 12 months as of April 2024 |
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? Dr. Stevenson Chery (CMO) lead the forums for all PCPs. Yes, has the skills and time to complete. The providers attended, engaged, and implemented what they learned. Yes, has the skills and time to complete. |
How will you know if clinicians/care teams/sites used the intervention? Run reports on clinical reference use and as well as net change in statin uds performance. | What proportion of the planned staff/sites implemented the intervention? 100% 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.)? N/A |
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? All scheduled forums were executed. Patient’s received improved quality of care which is reflected in UDS performance. |
What might be some of the possible obstacles to consistent implementation? | What were the barriers to consistent intervention implementation? Time & staffing (Ex: Making time to have the 1:1s) |
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? Availability of staff |
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: | What reinforcements did you put into place to sustain the intervention?
Explain: |
How will you spread your intervention and lessons learned? | How will you spread your intervention and lessons learned? Awarding sites for all other CQ measures to encourage understanding of measures and drive performance. |
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)? Staffing, reinforcement, maintaining transparency, consistency with driving measure and open communication of results | |
)Intervention #2 Plan | Intervention #2 Actual |
Describe Intervention Chosen intervention: PCN Previsit Planning Plan for intervention:
| Chosen Intervention: PCN Previsit Planning Date when implemented: Nov 2023 Updates: Has been an ongoing process over last 2 years to improve this planning, but latest successful approach began last year and has been going well! Using print out from Epic and documenting care gaps for provider. Planning done by EOD in preparation for tomorrow morning’s huddle. Huddles are provider led. |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers?
| Reach of implementers/providers? Actual: 2.5 FTE PCNs |
Reach of patients?
| Reach of patients? Actual: AA to pull how many MH patients were seen since Nov 2023 Out of 597, 295 have been seen since Nov 2023 |
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? Provider feedback that providers know what to expect and can anticipate tx for patient when they arrive. Reference reach #. |
What outcomes do you expect? Increase in Statin Rx & cholesterol screening measures | What outcomes have you seen? Increased provider & team engagement (providers, MAs, HIM, etc) resulting from increased collaboration. Feeling successful in care delivery because of preparation. |
How will you ensure your intervention will be effective for your target population? Cohort f/u and rx performance increase | Did your intervention reach the target population? Yes by identifying gaps and opportunities in advance, preparing for conversation about statins if appropriate. |
What unintended consequences or outcomes might there be? | What unintended outcomes did you experience? Added additional focus on HTN because noticed that statin therapy compliance is greater. Pop health also focusing on IVD. Goal to bring both up to meet statin therapy. |
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. PCNs (n=3, across 4 sites) | Who delivered the intervention? Did they have the skills and time needed to complete the intervention? PCNs completed intervention. They have the skills & time. |
How will you know if clinicians/care teams/sites used the intervention? restructured daily huddle - reporting on patients coming in - challenge is that the patient must be on schedule on the prior day, QI nurse is put in PHN role 1 day/week and looking at patient screenings and care gaps, including statin therapy | What proportion of the planned staff/sites implemented the intervention? All sites implemented the process, all staff were involved. 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.)? N/A |
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? using Epic huddle form with addition of statin therapy piece (handwrite on huddle form), can look at paper form to see if they are followed or not - scanned into folder and can go back and check statin piece | How did you track modifications during the intervention? Email and conversation, modifying process based on care team feedback. |
What might be some of the possible obstacles to consistent implementation? | What were the barriers to consistent intervention implementation? Not having every provider understand huddle process and how it should benefit them. Dr. Chery visited each site and walked them through the value of the process. Having stronger providers champion the process for their site. Increasing understanding on how process makes their day easier. |
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? Hiring of PCN, getting buy in from all staff. |
How closely did the staff/sites follow the intervention design and deliver as intended? Check all that apply:
Modifications made and other notes: Included statin as part of broader focus on heart health | |
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: reports are ran monthly to see changes | What reinforcements did you put into place to sustain the intervention?
Explain: |
How will you spread your intervention and lessons learned? | How will you spread your intervention and lessons learned? Spread the use of incentives across all clinical quality measures, driving attention on all which will impact previsit planning and huddle conversations. |
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)? Creativity and flexibility! Frequent analysis of outcomes to ensure process remains effective and modify as needed. | |
Add Comment