First Choice Intervention Assessment

Internal Characteristics

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

First Choice Health Centers serves over 22,000 patients across central Connecticut with 11 locations in East Hartford, Manchester, and Vernon. We are proud to provide integrated care and break down social and economic barriers to wellness and healthy living.

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

Our services include Primary Care, Pediatrics, Women’s Health, Dental, Behavioral Health, Chiropractic, Nutrition, LGBTQ+, Optometry, Podiatry, Medication Assisted Treatment, Pharmacy, and more.

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

We need to ensure all patients are being targeted. This includes patients coming in for appointments in addition to outreach to patients who have been lost to follow up. We need a team that can speak both English and Spanish and be able to use interpreter services for other languages. We need to have defined workflows and resources for patients who have socioeconomic barriers to any gap in care.

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)?

Our project interventions range from easy to complex. An example of an easy intervention to implement is sending out a broadcast message to hundreds of patients at once, perhaps those who are due for screening. This only takes a few minutes to set up and send. We may also have a team member add reminders to patient visits to highlight a gap in care to the provider. We try to maximize these “easy” interventions with all of our projects and implement more complex strategies if staffing and expected reward/benefit allows. This project’s main intervention is a good example of this.

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

Most often at a Primary Care clinic.

External Characteristics

What external or environmental supports or threats are there?

External – being able to access pharmacy records and/or outside specialist records is improving, though we still struggle with proper documentation especially with ASCVD history. We also have the support of telehealth in the event the patient has a barrier and can’t physically come to the clinic.

Plan

Actual

Describe Intervention

Chosen intervention:

Clinical Pharmacist and students will chart review patients with DM, who are non-compliant for statin metric & review statin intensity..

Director of Performance Improvement, will perform chart audits on patients with LDL > 190

Plan for intervention:

List will be provided to this team to outreach, focusing on LDL >190.

Chosen Intervention:

Date when implemented: October 2023 (DM), November 2023 (LDL >190)

Updates:

clinical pharmacist and students did outreach

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

Reach of implementers/providers?

Planned:

3 (1 Clinical Pharmacist + 2 students)

Reach of implementers/providers?

Actual:

Reach of patients?

Planned:

80

Reach of patients?

Actual:

Over the months of September/October:

• LDL > 190 - 53 patients (of those 11 patients were corrected); sent telephone messages to 34 patients to schedule appts, remaining 8 patients refused statins.

• DM: 300 patients total; 41 patients

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working?

# patients of our planned reach that we actually reached. Of those, # patients switched to the compliant category.

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

• Performed chart audits and monitored data.

What outcomes do you expect?

We expect to identify patients who have refused statins in the past and will likely always remain “non-compliant”, but we will find more patients who are eligible for statins and we will be able to intervene.

What outcomes have you seen?

• Positive outcomes. Have new providers/reminding all providers for LDL > 190 need to be on statins/continuous education among providers.

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

Measure outcome of # patients moved to compliant category and ideally, track therapeutic goals.

Did your intervention reach the target population?

• Absolutely! (please add numerator and denominator)

What unintended consequences or outcomes might there be?

Expert Consensus still not published as guidelines yet, so it remains unclear which direction we should counsel providers in.

What unintended outcomes did you experience?

• Still need clarity around guidelines -

• Linda Murakami AMA cholesterol management risk groups - will send recording and include here

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.

Clinical Pharmacist and students followed by Providers implementing the decisions of statin Rx.

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

• Clinical pharmacist/pharmacy students/Director of Performance Improvement

• Having the pharmacy students allowed time to focus on this intervention.

How will you know if clinicians/care teams/sites used the intervention?

Tracking lists of patients

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

• Implemented across 8 sites

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.)?

• Newer providers had more opportunities d/t newer panels of patients and having more time to talk to patients. Older providers have more established panels, therefore making it difficult to have those conversation.

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?

Patient list/tracking

How did you track modifications during the intervention?

• N/A, there were no modifications made to the intervention.

What might be some of the possible obstacles to consistent implementation?

Frequent chart review and education to providers

What were the barriers to consistent intervention implementation?

• Pharmacy students are seasonal, staffing challenges, including provider turnover,.

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

Time is the biggest one. Time to chart review, send messages with recommendations to providers, time to outreach to patients, etc.

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

• Time

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: December 2023 clinical pharmacist conducted a training with providers on LDL> 190 and statin use.

How will you spread your intervention and lessons learned?

Review of the chart reviewed data overall with teams

How will you spread your intervention and lessons learned?

• Continuing to do annual provider education on statin therapy. Clinical pharmacist reviewing lists of pts sched to come in within 2 weeks among providers to make recommendations ahead of time to providers-send telephone encounter to providers.

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)?

• Ensuring taking advantage of pharmacy students while there to review lists of patients.

Intervention #2

Plan

Intervention #2

Actual

Describe Intervention

Chosen intervention:

Review quality metrics, including statin therapy, with each Care Team one-on-one

Plan for intervention:

Block dedicated time for site visits with each Care Team

Chosen Intervention:

Date when implemented: Twice in 2023, upcoming in Feb 2024. Goal is to do this quarterly.

Updates: Last round of reviews completed with providers April 2024.

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

Reach of implementers/providers?

Planned:

12 providers

Reach of implementers/providers?

Actual: 12

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?

Quarterly review to continue tracking trend

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

• Successfully blocking time and following through to complete reviews.

What outcomes do you expect?

More awareness of quality performance and workflow changes from Care Teams

What outcomes have you seen?

• Successfully reached all 12 providers. Was able to identify common issues among providers with documentation.

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

Live meetings vs. emailed data

Did your intervention reach the target population?

• Yes. Director of Performance Improvement met one-on-one with providers to review quality metrics, including statin therapy.

What unintended consequences or outcomes might there be?

Providers not available for the meeting. Turnover.

What unintended outcomes did you experience?

• Challenging to navigate teams with high turnovers/staffing shortages. Clinical team is not always as stable, making it challenging to meet with the entire clinical team.

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.

Director of PI + PI Associate

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

• Director Performance Improvement & PI Associate delivered the intervention, and made the time to complete.

How will you know if clinicians/care teams/sites used the intervention?

Attendance at the meeting

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

• Across 8 sites

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.)?

• A couple of providers that were leaving the clinic were not as motivated regarding the intervention.

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?

Tracking performance of the metric by provider

How did you track modifications during the intervention?

• First round of visits were performed in-person, second round of visits were performed in-person. Last round of intervention was mostly in-person, with one provider done virtually.

What might be some of the possible obstacles to consistent implementation?

Turnover

What were the barriers to consistent intervention implementation?

• Staffing challenges and when doing in-person visits, finding a day when all providers were available, making scheduling difficult.

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

Time to run reports and block schedules for the providers to have dedicated time to meet.

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

• Time, blocking patient slots for meetings which costs the clinic dollars.

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: Provided graphs for each provider that shows their performance vs. First Choice overall performance vs. national and state averages. Summary provided to providers, sharing strengths and opportunities for improvement.

How will you spread your intervention and lessons learned?

General debrief at provider meetings.

How will you spread your intervention and lessons learned?

• Plan ahead for the entire year with scheduling meetings with providers; making it a regular intervention.

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)?

• Plan ahead for the entire year with scheduling meetings with providers; making it a regular intervention. Still in the process of learning Relevant to use to the organizations advantage. Using Relevant to present the data and retrieve the data.