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Important Health Center Context Fill out this section during your planning process | |
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Internal Characteristics | |
What are the characteristics of your health center? (rural/urban; other demographic variables, use of expanded care team, culture)? | Urban, refugee/immigrant population, non-English speaking |
What are the infrastructure characteristics of your health center (use of expanded care team, culture)? | Team Based: Clinical Pharmacist, Providers, Nursing Team, Triage Nurse, Care Management |
How do interventions and/or workflows need to be adapted to ensure health equity? | WMY is focusing on all populations for Statin needs |
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)? | WMY has re-pivoted frequently with workflows related to this initiative (primarily related to staffing challenges). Goal is to “meet patients where they are at.” |
What are key characteristics of the participating setting(s)? | Clinic real-time patient facing, phone outreach. We feel the clinic real-time patient facing is most effective to patient engagement for Statin Project. |
External Characteristics | |
What external or environmental supports or threats are there? | Unite Us Referral Platform is used to meet any SDOH needs based on positive screens. For example: patient ability to afford medications, or need for health insurance. |
Plan | Actual |
Describe Intervention: Statin Therapy: needs identified by looking at “whole patient” diagnosis such as DM, HTN, elevated LDL > 190 or hypocholesteremia, ASCVD are the focus. Triage Nurse, clinical pharmacist and Care Manager following patient will review chart to ensure patient is identified as qualifying for statin treatment (missed opportunity). The team ensures patient has a follow up apt. in place. Triage nurse will refer patients to clinical pharmacist to make recommendations to provider for statin therapy. Health Equity focus: All populations with HTN/Statin Therapy. Chosen intervention: Identify patients with diagnosis of HTN and DM not on statin therapy who are being followed for HTN and or any triage patient calls the triage nurse is consulted for (triage nurse refers patient to clinical pharm.). Plan for intervention: Triage nurse, clinical pharm. and Care Manager will inform provider of patients need for statin therapy. Team meets twice per month to discuss patients being followed for HTN/Statin therapy. Challenges to patient outreach, patient engagement, patient engaged plan of care discussed and consider workflow changes to challenges identified. Banners and buttons created for patient awareness to HTN/Statin/DM. | Chosen Intervention: Evidence based Guideline treatment recommendations: Antihypertensive medications for patients with uncontrolled HTN. Statin therapy prescribed for those patients with a HTN/diabetes diagnosis, and elevated cholesterol risk. Date when implemented: Post Million Hearts Harvest Meeting (June 2023). Updates: Clinical Pharmacist has been active in real-time reviewing patient scheduled as a “pre-visit” plan approach to evaluate patients medication needs and or if the medications prescribed are in fact working for the patient and align with the evidence based recommended treatment regimen. She has been an asset to the providers in providing appropriate recommendations. Meeting with Triage Team Monthly: Triage states that Nursing Team has not sent referrals to Triage for Million Hearts since Mid November 2023. Plan to re-educate Nursing Team. Report (includes HTN, pts on statin therapy, patients not on statin, & DM patients) pulled from the month of December shared with Triage Team to work list and out reach patients on list. More robust huddle/pre-visit planning, as the clinic is still working on their DPI program with Coleman and Associates. This helps gather data prior to patients coming into the clinic. Clinical pharmacist also provides education to the nursing staff to ensure nurses have the proper education for patients. |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: 7-8 providers
| Reach of implementers/providers? Actual: 7 adult providers and 2 OB providers. |
Reach of patients? 25 patient due to staffing deficit Planned: Triage nurse following 30 patients for statin. Care Managers identifying transition of care patients (Statin) approx. 20 patients per week. 7-8 providers, 4-5 providers the nursing staff conduct pre-visit planning to identify missed opportunities. | Reach of patients? 30 patients are being followed between Triage and Clinical Pharmacist. Clinical Pharmacist meets with patient in real-time (Her schedule: on average 5 per day). Nursing Staff and pre-visit planners conduct pre-visit planning for providers. Clinical Pharmacist is also conducting a pre-visit medication need for the those patient being seen for HTN/DM to ensure a statin is ordered and or any follow up appointment types on the schedule. Care Management conducts a medication review with all patients being seen for Transition of Care/post hospital discharge outreach and refers to Clinical Pharmacist. Clinical Pharmacist is also conducting a medication rec. for all patients who are Transition of Care (TOC) with 10 or more medications. Triage is following 30 patients currently for Million Hearts Program. 2 adult Care Managers are following 75-100 patients each, to include patients with chronic conditions such as HTN/DM, CVD. Majority of their patients are Transition of Care Patients. Actual: Met with Relevant in 12/2023 to review data collected for Million Hearts Project and how it is being pulled from Athena for Validation. Relevant is to report back to the team once validation is complete. Stain Therapy for the Preventative Treatment of Cardiovascular Disease: Baseline prescribing: July 1, 2022-June 30, 2023 82.1% statin therapy 1044/1272 July 1, 2023- June 30, 2024: 87.3% statin therapy compliance rate (1059/1213) 1/8/24: Managed Care Organization (CDPHP) shared data: Whitney M Young Jr. is now 5 star with Statin Therapy. |
Efficacy (Impact of intervention on important outcomes) | |
How will you measure that your intervention is working? 1. Met with Relevant in 12/2023 to review data collected for Million Hearts Project and how it is being pulled from Athena for Validation. Relevant is to report back to the team once validation is complete. 2. Pull Relevant data frequently for review. 3. Continue to meet with Triage Team, Care Management Team to review workflows and results (How are the workflows working?), How are patients engaging with the program? What are the opportunities for improvement of process and patient engagement? | Were you able to accurately measure how your intervention was working? Yes. Data has been helpful and meaningful to identify the need to validate our data with Relevant. We met with Relevant recently and currently waiting for those results. Monthly team meeting has been helpful to identify the opportunities and to ensure that all team members are following the workflow. This helps to identify any opportunities for re-educating staff to workflow. |
What outcomes do you expect? Increasing patient awareness with our patient awareness buttons/poster asking “do you know your numbers? Ask me.” Improving health outcomes by ensuring team is educated to the evidence based recommendations provided around treatment of Statin Therapy treatment. | What outcomes have you seen? 1/8/24: Managed Care Organization (CDPHP) shared data: Whitney M Young Jr. is now 5 star with Statin Therapy earned 5 star recognition with statin therapy. Our Relevant data for Statins has continued to rise towards positive outcomes. |
How will you ensure your intervention will be effective for your target population? Continue to meet monthly with staff and share/review data with all staff, continue to provide education to team. Continue to create patient awareness as a prevention. | Did your intervention reach the target population? Yes. We take a health equity approach and look at all populations who are identified as exhibiting signs of/or actual Diagnosis for DM & HTN, elevated cholesterol levels, and in need for Statin treatment. |
What unintended consequences or outcomes might there be? Nursing staff diverting from workflow and not referring patient to Triage Team for Million Hearts Program. This was identified in the monthly second BP check data. | What unintended outcomes did you experience? Improving our medication efficacy. This data has been challenging to get providers buy in. Currently it shows we are slowly rising towards positive outcomes. Staffing changes led to a diversion of workflow, identifying based on report mentioned above that patient were not being referred to Triage RN for follow up. |
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. Triage Nurse Team, Adult/OB providers, clinical pharmacist, Care Managers for Adult populations seen at all WYH sites: Albany clinic, Watervliet Clinic, Troy clinic, Swinburne Clinic (OB Population). This team has been working with providers to create awareness around the need for treatment related to statin therapy. | Who delivered the intervention? Did they have the skills and time needed to complete the intervention? Triage Nurse Team, clinical pharmacist, Care Managers, Providers, Nurses. Referrals sent to the clinical pharmacist to meet with patients who are struggling with medication side effects or need additional education to assist patients with medication compliance. Clinical pharmacist meets with patients in real-time in the clinic to assist providers in this regard as well. Clinical pharmacist also offers providers other medication treatment alternatives (less side effects for example) to improve patients health outcomes and medication compliance. Providers educate patients and prescribe statin therapy medications for patients. Providers and nurses also participate in huddles, where patients are identified as having a need for statin therapy. |
How will you know if clinicians/care teams/sites used the intervention? Frequent communication is key. Maintain Monthly meeting with teams to evaluate and take a deeper dive into data, opportunities related to workflow and patient engagement, evaluate if workflows are working and tweak them as needed for effectiveness, re-educate staff as needed based on findings. | What proportion of the planned staff/sites implemented the intervention? All clinic sites, nursing staff, care management staff, Adult/OB Providers 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.)? Swineburn location is the only location that provides OB services. OB populations seem small. We have just begun to focus on OB populations for HTN/DM/Statin treatment and hoping this data will increase in number. |
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? Documented Monthly meeting minutes, email correspondence with team, education/data sharing with provider team, Triage Team, Nursing Team, Care Management Team. | How did you track modifications during the intervention? Documenting results shared in monthly meetings with teams as we take a deeper dive into the workflow, patient engagement, to identify areas of opportunity. |
What might be some of the possible obstacles to consistent implementation? Staffing: Lack of providers, and nursing has open positions as well | What were the barriers to consistent intervention implementation? Staffing challenges with Nursing. Have multiple openings for family medicine providers, along with shortages in the care management staff. Currently, have 1 adult care manager. Lack of experienced staff. |
What costs and resources (including time and burden, not just money) need to be considered? Having enough staff to participate in the program. Monthly Meeting participation, workflows being followed to achieve the positive health outcomes and goals set for the program's success. | What costs and resources (including time and burden, not just money) need to be considered? Monthly meetings, outreach to patients require staff, purchase of buttons and posters to create patient awareness, data team time/awareness to validate data in our check in discussions. However, even though there is much time to achieve/accomplish these goals, this program has been useful to help our patients improve their lifestyles towards preventative, positive health outcomes. The data shred with WMY from our Managed Care Organizations reflect this work and the positive impact it is having towards the ultimate goal of a VBP arrangement. Increasing marketing of “Know your numbers”. Working to create more awareness among patients, communities, and donors regarding SDOH needs in the population, which creates barriers to care. Buttons/banners created awareness among patients. |
How closely did the staff/sites follow the intervention design and deliver as intended? Check all that apply:
Modifications made and other notes: Nursing staff has been identified for the month of 12/2023 not referring patients to Triage Nurse Team for Million Hearts. Plan to re-educate Nursing staff to the workflow. Re-pivoting workflow has been needed to meet the staffing need. Continuous re-education (at least QTRLY to ensure new staff are educated to workflow). Keeps line on communication open, consistent with meeting with staff to discuss intervention. Staffing challenges are a consistent barrier. | |
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: Sharing the data and any new evidence-based education to keep providers informed on treatment options. We are working with marketing team to create patient awareness with a banner for clinic asking patients if they know their numbers Staff will also wear a button type pin on uniform with same message. | What reinforcements did you put into place to sustain the intervention?
Explain: Frequent sharing of data with providers. Also sharing any education related to evidence-based treatment related to Statin therapy. |
How will you spread your intervention and lessons learned? Ensuring the team has frequent communication/discussion about what is working and what is not. Education / Updates to project sharing data with providers and staff. | How will you spread your intervention and lessons learned? Monthly meetings with team to explore what is working and what is not. Sharing the data to encourage team to press on as it continues to improve. |
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)? Frequent education with nursing staff/provider as new staff on-board. Vacancies among staff filled. | |
Intervention #2 Plan | Intervention #2 Actual |
Describe Intervention Chosen intervention: Clinical Pharm. Pulling data reports for ASVD cohorts, LDL > 190, and out reaching 10-15 patients per week across all three clinic locations. Care Manager is also looking at transition of care patients and adding the statin need to the chart prep for provider to weigh in on (missed opportunity). Clinical Pharm. will also provide recommendation for patient who are having side effects and not compliant with statin therapy as a result. Plan for intervention: Clinical Pharm. will provide recommendations for provider to consider if a patient is identifying side effects from a statin. Clinical pharmacist to outreach 10-15 patient per week. Clinical pharm. also looking at the provider scheduled patient visits for week to perform a chart review for patients dx. With HTN, DM, LDL > than 190, ASCVD and identify missed opportunities. | Chosen Intervention: Date when implemented: Updates: February 2024 meeting where the assistant medical director and clinical pharmacist provided education to the providers regarding patients with a diagnosis of DM and HTN, and the need for statin Rx. Also have triage nurse outreaching patients within these cohorts. March 2024 Nursing staff provided education in regards to workflow and pre-visit planning opportunities to identify patient with HTN/DM who are NOT being treated with a statin. Clinical Pharmacist is also working with nursing team on this initiative. |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: 7-8 providers | Reach of implementers/providers? 7-8 Providers Actual: 30 Patients |
Reach of patients? 25 Planned: 10-15 patient per week | Reach of patients? 10-15 Actual: Clinical pharmacist meeting target goals of 10-15 patients per week. Performing PVP for the week. Sees the patient in real-time. Triage nurses leaving messages for patients-outreach may be slightly less than the clinical pharmacist. Clinical pharmacist also following-up with patients who received a new statin therapy prescription. Triage nurse also able to perform real-time interactions with patients. |
Efficacy (Impact of intervention on important outcomes) | |
How will you measure that your intervention is working? Monitor and review data. | Were you able to accurately measure how your intervention was working? Reviewing run charts monthly. Will work to validate data-look at patient level data. Data (second BP check data) is reviewed monthly to ensure that workflows are being followed in regards to the referral process. |
What outcomes do you expect? Decrease in number of patients who are not on a statin medication that have HTN, DM w/ LDL > than 190, ASCVD, or LDL>190. | What outcomes have you seen? WMY has continued to improve data related to Statin Therapy and gain 5 star recognition with Managed Care Organization (CDPHP). |
How will you ensure your intervention will be effective for your target population? Will review and evaluate data during recurring meetings. | Did your intervention reach the target population? Yes (All Populations have been the target for WMY to ensure Health Equity. |
What unintended consequences or outcomes might there be? Lack of engagement among providers, and lack of engagement among patients. | What unintended outcomes did you experience? SDOH needs. If providers/nurses are engaged, would be easier to have the patients more engaged. Staffing deficit led to re-pivoting workflows to meet the needs of the program. |
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 all staff and sites, if applicable. Clinical Pharmacist, Triage Nurse, Providers, Care Management Team. (45-50 total for all sites). | Who delivered the intervention? Did they have the skills and time needed to complete the intervention? Previous mentioned team saw patient in real-time in the clinic as well as prepared with pre-visit planning as to what the patient treatment needs would need addressing, for patient with HTN/DM and not being treated with a statin. Patient education was initiated with medical team/clinical pharmacist. One Triage Nurse works virtually to preform out reach/follow up to patients. |
How will you know if clinicians/care teams/sites used the intervention? Through data collection and recurring meetings. Frequent communication is needed to understand the opportunities. | What proportion of the planned staff/sites implemented the intervention? all sites (Albany, Troy, Watervliet and Swinburne Clinic). 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? Through data collection and reviewing during recurring meetings. Frequent communication with staff is key to identifying real time opportunities. | How did you track modifications during the intervention? Meeting Minutes and education agenda when re-educating staff and providers. |
What might be some of the possible obstacles to consistent implementation? Staffing: Lack of providers, and nursing has open positions as well | What were the barriers to consistent intervention implementation? Staffing deficit. Workflow re-pivot occurred frequently throughout the coarse of the project related to staffing deficits. |
What costs and resources (including time and burden, not just money) need to be considered? Having enough staff to participate in the program. Monthly Meeting participation, workflows being followed to achieve the positive health outcomes and goals set for the program's success. | What costs and resources (including time and burden, not just money) need to be considered? Sufficient staff would eliminate burden of re-pivoting workflows to meet the need. Due to the limited staff, many staff are performing additional task in their role to meet the staffing deficit needs. |
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: Sharing the data and any new evidence-based education to keep providers informed on treatment options. We are working with marketing team to create patient awareness with a banner for clinic asking patients if they know their numbers Staff will also wear a button type pin on uniform with same message. | What reinforcements did you put into place to sustain the intervention?
Explain: Clinical Pharmacist is currently placing protocols in place around medication management. QTRLY training to workflow, referral process for both triage and Clinical Pharmacist is essential as new staff on board. Clinical Pharmacist is also training providers in relation to medication engagement/ensuring statins are ordered for those patients at risk for stroke and heart attack. |
How will you spread your intervention and lessons learned? Ensuring the team has frequent communication/discussion about what is working and what is not. Education / Updates to project sharing data with providers and staff. | How will you spread your intervention and lessons learned? Frequent communication is key, to ensure staff feel supported. Engaging staff to share ideas around workflow exploring efficient processes. QTRLY Education is key to ensure new staff are aware of project, importance of this work, why we are focusing on this project and send the message that they are key contributors to ensure a patient has positive health outcomes in preventing stroke and heart attack. We have included the marketing team to post to the importance of cholesterol treatment on our website to create community/patient awareness. Posters and buttons (to be worn on lapel) are part of our goals to create patient awareness. All clinics have posters hung asking patients if they know their numbers around (HTN/DM/Cholesterol). |
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)? Staff support and marketing the cause. | |
| Version | Date | Comment |
|---|---|---|
| Current Version (v. 12) | Aug 19, 2024 18:30 | Trudy Wright |
| v. 14 | Aug 19, 2024 18:37 | Trudy Wright |
| v. 13 | Aug 19, 2024 18:36 | Trudy Wright |
| v. 12 | Aug 19, 2024 18:30 | Trudy Wright |
| v. 11 | Apr 17, 2024 20:27 | Laurie Levasseur |
| v. 10 | Apr 15, 2024 19:03 | Trudy Wright |
| v. 9 | Apr 10, 2024 16:38 | Laurie Levasseur |
| v. 8 | Mar 18, 2024 19:00 | Trudy Wright |
| v. 7 | Jan 10, 2024 16:37 | Trudy Wright |
| v. 6 | Jan 05, 2024 18:58 | Lauren Becker |
| v. 5 | Dec 21, 2023 17:50 | Trudy Wright |
| v. 4 | Oct 16, 2023 17:37 | Michelle Tropper |
| v. 3 | Oct 16, 2023 17:35 | Michelle Tropper |
| v. 2 | Oct 13, 2023 18:53 | Lauren Becker |
| v. 1 | Sept 18, 2023 20:38 | Lauren Becker |
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