Hometown Intervention Assessment

Internal Characteristics

What are the characteristics of your health center? (rural/urban; other demographic variables)?  

Hometown Health Centers (HHC) is in a densely populated suburban area within the Mohawk Valley region of NY with a population of over 66,000. HHC is nationally recognized for providing high quality, cost-effective primary health care to all in need, with particular concern for low-income residents. HHC offers the main dental facility which accepts Medicaid within the entire county. The city of Schenectady has a diverse population but ranks below the national average for graduation from a bachelor’s program or higher (approx. 22%), however, almost 85% have graduated from HS. Approximately 20% are living in poverty.  We employ a very diverse staff and offer multiple translation options in both site locations.

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

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

There is a large population in Schenectady County (nearly 16% in 2021) of residents who were born outside of the country – we need to ensure that we are offering appropriate services. For example – a recent migrant population was placed in Schenectady County, and the county itself was unprepared with a plan of how to best help. As a result of this placement, many community organizations came together to formulate a plan – more of this type of partnering is needed within the county to promote more health equity. We have recently implemented the inclusion of patient race/ethnicity within our reporting system and are now able to drill down for all of our monitored quality measures in an effort to evaluate health inequities within our organization.

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)?

Funding sources are always a challenge in the services we provide as this can hinder our growth as an organization. Programs which would benefit our patient population oftentimes come with funding shortages, etc. which puts us at a disadvantage. Staff shortages are also posing big issues for us as an FQHC in terms of inability to participate in projects we would otherwise love to be a part of due to conflicting priorities, etc.

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

As an FQHC, we offer Primary Care (including geriatrics and pediatrics), Behavioral Health, Dental, OB/GYN, and onsite lab/pharmacy services. HHC operates a main site location in Schenectady, NY with a satellite site in Amsterdam NY, and has 2 SBHC clinics, as well as offering Dental Outreach in Schenectady schools. We have a very diverse staff who are all trained Cultural Awareness and have ongoing Customer Service training. Due to this, staff are mindful of cultural uniqueness and are dedicated to continuous improvement. Like many in the health care setting, we are faced with issues such as short staffing and staff burnout.

External Characteristics

What external or environmental supports or threats are there?

HHC partners with several community agencies and providers within our geographic area. We pride ourselves on those close relationships as they are a factor in patient engagement with our practice. There is, unfortunately a shortage of dental providers in our area who take Medicaid, and this has presented a huge problem for our area. Patients are frustrated with long wait lists as a result and are not able to be seen within an acceptable timeframe for them.

Plan

Actual

Describe Intervention

Chosen intervention: Provide Statin Education to providers during regularly scheduled provider meeting – CDPHP to come onsite. Awaiting presentation.

Plan for intervention: CDPHP to come onsite for 1-hour educational session during provider meeting on a TBD date.

Chosen Intervention:

Date when implemented:

Updates: Received presentation from CDPHP on 2/5/24, sent to CMO for approval. Once approved, date will be scheduled for educational session with providers. Shared resource from NACHC: recording from NACHC on “Statin Management in High Risk Groups” by Kate Kirley.

(additional note: health center is looking to implement POC cholesterol testing)

The NACHC “Statin Therapy for High Risk Groups” video will be presented on March 14th at the provider meeting. Video actually presented during meeting on March 15.

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

Reach of implementers/providers?

Planned: 18 providers

Reach of implementers/providers?

Actual: 14 patients

Reach of patients?

Planned: N/A

Reach of patients?

Actual:

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working? Pre/post-test or provider feedback

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

What outcomes do you expect? Improved test score from pre to post-test.

What outcomes have you seen?

How will you ensure your intervention will be effective for your target population? CMO to review presentation for appropriateness.

Did your intervention reach the target population?

What unintended consequences or outcomes might there be? Provider frustration/pushback at pre/post-tests.

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. CDPHP to present at Schenectady site in conjunction with CMO/QM.

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? Meeting attendance.

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? Provider engagement with presenters/CMO.

How did you track modifications during the intervention?

What might be some of the possible obstacles to consistent implementation? Staff call outs/provider schedules.

What were the barriers to consistent intervention implementation? Not all providers present during March 15 meeting.

What costs and resources (including time and burden, not just money) need to be considered? Provider Time: 1 hour block to provider schedules

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: If proven effective, we may offer regular trainings by CDPHP or other plans. Potentially will develop a protocol.

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? Touchbase with providers at 1 month post training to get provider feedback on what’s working/what’s not, etc.

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)? Feels the provider buy-in and engagement is present. Have some difficulties coordinating staffing schedules to have all providers present.

Intervention #2

Plan

Intervention #2

Actual

Describe Intervention

Chosen intervention: Patient outreach (2) weekly, utilizing Relevant report. Focus on patients with LDL >= 190 who are not on statin.

Plan for intervention: Case Manager to outreach via report weekly

Chosen Intervention:

Date when implemented:

Updates: Set-up an excel spreadsheet on 2/2/24. Will start the week on 2/5/24 outreaching patients.

Began reviewing patient charts on 2/5/2024 and will continue on a weekly basis.

Relevant report contains a list of patients with Diabetes and who have an LDL >= 190.

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

Reach of implementers/providers?

Planned: N/A

Reach of implementers/providers?

Actual:

Reach of patients?

Planned: 40 patients

Reach of patients?

Actual: 7 patients as of 2/20/2024. Out of the 7, 1 patient who had an elevated LDL wants to try lifestyle modifications prior to starting a statin.

14 patients as of 3/19/2024.

18 patients as of 4/2/2024.

21 patients as of 4/16/2024.

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working? Via monthly data pull of patients with LDL greater than or equal to 190 who are on prescription.

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

Track quarterly. Review monthly data with HealthEfficient.

What outcomes do you expect? We would expect that number of patients who have LDL greater than 190 who are actively on prescription would increase.

What outcomes have you seen?

Increase noted in prescriptions provided to patients with LDL >= 190 from July 2023 (11.8%) to February 2024 (20.5%). Since the last learning lab, asking patients how are you taking your medications and how often, rather than asking if they’ve filled their Rxs. Implementing this method allows staff to get more information from the patient regarding if they’re taking their Rxs.

How will you ensure your intervention will be effective for your target population? This will tie back to reports and monthly data.

Did your intervention reach the target population?

Targeted outreach via Relevant reports on the LDL>= 190 and Diabetes cohorts.

What unintended consequences or outcomes might there be? Patient refusal to take statin, refusal to engage in care, inability to contact patient, inability to afford medication.

What unintended outcomes did you experience? 1 patient wanted to try lifestyle modifications prior to starting statin prescription.

1 patient refusing to take statin medication.

1 patient last LDL in 2022, refused to have blood drawn for updated lab: will continue to outreach patient.

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. Case Managers in conjunction with the Manager of Case Management.

Who delivered the intervention? Did they have the skills and time needed to complete the intervention?

Case Managers in conjunction with the Manager of Case Management. Diabetic educator also encouraged to check for LDL labs, patient names forwarded to Manager of Case Management for f/u.

How will you know if clinicians/care teams/sites used the intervention? Supervision of spreadsheet by the Manager of Case Management.

What proportion of the planned staff/sites implemented the intervention?

Have a shared spreadsheet for both locations.

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.)? Amsterdam providers are performing lower overall than Schenectady providers according to the statin therapy report in Relevant database. OB provider’s patients are at a lower percentage than other providers.

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? Documentation via spreadsheet.

How did you track modifications during the intervention?

Documentation is being maintained regarding patient outreach on spreadsheets.

What might be some of the possible obstacles to consistent implementation? Decreased staffing in Case Management Department, competing priorities.

What were the barriers to consistent intervention implementation?

Time and resources continue to be a barrier to implementation. Also, delay in CLIA certificate for POC cholesterol testing is a barrier.

Difficulties contacting some patients: unable to leave voicemails, changing phone numbers, etc.

What costs and resources (including time and burden, not just money) need to be considered? Time with being short-staffed 2 Case Manager’s.

What costs and resources (including time and burden, not just money) need to be considered?

Time and staffing resources continue to be a barrier.

As of 3/19/2024 the case management department is fully staffed.

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: monthly report outs to CM staff

Explain: Pulling monthly data, reporting out to CM staff on updates

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: Discussion with CMO regarding policy/procedure on how often cholesterol screenings should be performed/follow-up visits should be scheduled after medication changes.

Had 1:1 meeting with CMO and discussed items noted above. Will validate if this language is within the policy.

How will you spread your intervention and lessons learned? Discuss at Interdepartmental/Quality Meetings, Statin (Diabetics) Quality Dashboard inclusion.

How will you spread your intervention and lessons learned? Quality meeting scheduled for May. Will discuss at interdepartmental meetings (April meeting cancelled, will plan for May).

Intervention has also been applied to the Diabetes education program. Cholesterol testing & lipid lowering therapy included on PVP reports, which is provided daily to care teams.

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)? Will likely discuss as a topic at case manager meetings regularly. Case manager meetings occurring weekly. Intervention has also been applied to the Diabetes education program. Staffing capacity and time.