Petaluma Intervention Assessment

Internal Characteristics

What are the characteristics of your health center? (rural/urban; other demographic variables, 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: Outreach to patients without a lipid panel in the last 3 years to engage in screening:

Plan for intervention: : Call Center calls patients who are due for lipid panel using standardized script - might be MA instead given their training - patients that they are part of care team working with PCP and need routine testing of cholesterol and f/u with primary care provider - come in - next steps would be lab and where patient would go

Results are used by PCP’s to guide prescribing and f/u care.

Goal: Lab ordered and completed prior to visit to have results during the encounter

Chosen Intervention:

Date when implemented:

Updates:

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

Reach of implementers/providers?

Planned: All providers at 2 sites

Reach of implementers/providers?

Actual:

Reach of patients?

Planned: 50 patients as pilot. Tiered approach – favoring those with established risk, given limited capacity, triaging these patients (comorbid htn and DM). As capacity increases will add.

Reach of patients?

Actual:

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working? Step 1: Does the patient complete the lab?

Step 2: Does the patient schedule a follow-up visit once lab is done?

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?

for initial conversation - follow up would be tailored on PCP - this is WIP

guiding patients and explaining importance - want to be affirmative for pts and not create fear - what language to include

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?

Staff capacity and competing priorities

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:Using Relevant during huddle to drive this intervention – right now only doing in reach when has scheduled visit. Incorporating review of charts of pts for those comorbid and need lipid screening. Outreach with focus on statin prescribing without other triggers might be less sustainable.

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?

HC trainings and Aliados Health peer groups.

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: Statin tool implementation (Statin and lifestyle infographic)

Plan for intervention: Outreach to patients who are identified as high-risk and not currently taking any form of statin therapy. Include pop health outreach process to send letter and tool to patients in advance of their visits. 

Chosen Intervention:

Date when implemented:

Updates: waiting for Spanish translation (has been sourced as of 11/27)

student pharmacist outreaching to eligible patients . Cohort of patients comp chart review looking for

contraindications liver, active hepatitis, why statin therapy appropriate based on ascvd risk, sending to pcp to invite to come back into care - pcp or student pharmacist schedule, also mailing out statin education -

have review 227 charts so far, of those 36 who were due for statin therapy and no contraindications and no reason why not prescribed, another 25 with a caveat in the charts. next step will be to look at patient records in subpopulation who had an appointment and those were started on statin therapy. Some of other patients were already on therapy or flatly declined/want to do lifestyle first. Smaller population of people who are not still engaged in care

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

Reach of implementers/providers?

Planned: Planned 50-60 providers across 3 sites 

Reach of implementers/providers?

Actual:

Reach of patients?

Planned: patients with diabetes (roughly 200-300 patients – roughly 150 would get the letter intervention pre-visit) 

Reach of patients?

Actual:

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working? Step 1: Proportion of patients who received the pre-visit letter and initiated a statin AND came in for a visit. 

Step 2: Received a statin after the visit.

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? Challenge – tracking list of patients who were sent/received a statin tool letter. Linking this pop health activity to the EMR would streamline the mailing and tracking process. Report pulls will need to be regular to determine if the intervention is working. 

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. . QI Team  

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? HC training and Aliados Health Peer meetings

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)?