Broward Community Health Intervention Assessment

Internal Characteristics

What are the characteristics of your health center? (rural/urban; other demographic variables, use of expanded care team, culture)?  

• Urban location

• Demographics:

  • 76% non-Hispanic, 23% Hispanic

  • 65% black/African American, 31% white

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

• Use of expanded care team: Primary Care and specialties such as nutrition, BH, Dental, Peds, OBGYN

• Culture: mostly afro-Caribbean/black African American

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

• Bridge to Wellness: program to address SDOH primarily transportation and food insecurity

• Participate in MH, TargetBP to address chronic disease conditions

• Patient care navigators (pre-visit planning, care gaps)

• Integrated BH team

• HCT team to address HIV diagnosed pts and HIV prevention

• Utilization of telehealth to deliver services

• Managed care department to review care gaps for HEDIS measures

• QI department reviews UDS performance and takes action monthly (PDSAs)

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)?

• Complexities are centered around time and other resources:

  • demand on provider time to address & implement

  • availability of support staff and other resources to operationalize interventions and evaluate outcomes

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

• Strong and engaged Clinical Director of Medical Services

• Ongoing training and competency evaluation of clinical support staff

• Open forum via Breakfast Club twice monthly to address provider & clinical support staff learning needs

• Support of PCN team for pre-visit planning

• Clinical decision support in Epic EHR (Care Gaps)

External Characteristics

What external or environmental supports or threats are there?

• Supports:

  • availability of grant funding for primary health care

  • strong community partnerships

  • strong partnerships with professional organizations (ex: AHA)

• Threats:

  • funding (Medicaid expansion in FL was declined)

  • Medicaid Redetermination impacts the patient demographic we serve

  • National data reports that most FQHC patients only come for one visit and then switch orgs (BCOM finds this too)

Plan

Actual

Describe Intervention

Chosen intervention: Provider Professional Development

Plan for intervention:

• CMO 1:1 which includes chart reviews (peer reviews), UDS cheat sheet, alignment with evidence based guidelines

  • Ongoing provider education on cholesterol guidelines & strategies to overcome patient hesitancy (motivational interviewing), fine tuning the way we share information and improvement efforts with providers (newsletter).

• Provider meetings: Portia provides QI overview

  • Each meeting a topic is selected - an issue is the amount of time to explore any topic - each month run providers list of patients who should be on statin therapy and sort by outcome (those not on statin and should be are at top of list.

  • heart health champion motivates performance

Chosen Intervention: Provider Professional Development

• CMO 1:1

  • Implemented: January 2023

  • Frequency: met with everyone initially, now offered as needed

  • Purpose: provider productivity, professional development, following evidence-based guidelines

• Provider meeting

  • Implemented: Today’s structure implemented Spring 2023

  • Frequency: Monthly

  • Purpose: show and tell, announcements/updates, productivity, UDS, clinical trends, special programs, finance, presentations from vendors/partners

• All staff meeting:

  • Implemented: a long time ago

  • Frequency: Quarterly

  • Purpose: Providers and staff hear updates together (Quality Improvement is led by Portia & Dr. Chery)

• Biweekly Breakfast Club:

  • Implemented: July 13, 2023 (after MH Harvest meeting )

  • Frequency: 2x/month

  • Purpose: specific clinical topic each month

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: AA to make report. Statin UDS denominator, who received a MH clinical reference for statin therapy.

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working?

• Epic UDS data for statin therapy

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

• Yes

What outcomes do you expect?

• 82% of patients at high risk for a cardiovascular event will be prescribed a statin.

What outcomes have you seen?

• 84% rolling 12 months as of April 2024

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

• Monthly data analysis

Did your intervention reach the target population?

• Yes

What unintended consequences or outcomes might there be?

What unintended outcomes did you experience?

• Increase in all heart health CHQR Badge measures because we view them all together

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:

• 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:

• 1:1s transitioned to “as needed”

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?

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:

• PCN provides information to providers in advance of provider-led huddle

• Working on attaining pop health nurse. In meantime, QI nurse (Natasha) to commit 1 day/week to work on pop health activities, pending approval.

  • Managed care team will support Natasha in pt outreach in advance of appt to managed care pts

  • PCNs outreach to other pts (divide & conquer)

Chosen Intervention: PCN Previsit Planning

Date when implemented:

Updates:

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

Reach of implementers/providers?

• Planned: 2 PCNs

Reach of implementers/providers?

Actual: 3 PCNs

Reach of patients?

• All BCOM patients all 3 risk groups, n=TBD

Reach of patients?

Actual:

reports are in Epic, can run them 3/8 and populate then

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working?

• Possibly look at people coming in and completing visits

• More ASCVD & Hyperchol / LDL patients receiving statin rx.

• improvement in cholesterol screening and UDS report outcomes

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

What outcomes do you expect?

Increase in Statin Rx & cholesterol screening measures

What outcomes have you seen?

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?

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.

PCNs (n=3, across 4 sites)

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?

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?

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?

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?

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?

Availability of staff (ex: support staff to conduct reviews, outreach, etc)

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: reports are ran monthly to see changes

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)?