CDC 1422 Grant: The Philly Difference, Connections for Better

Chronic Care

A Partnership with the Philadelphia Department of Public Health

Health Federation of Philadelphiawww.healthfederation.org

Funded by the Centers for Disease Control and Prevention, through the Philadelphia Department of Public Health

 

A sub-awardee under the Philadelphia Department of Public Health grant with the goals of promoting high quality clinical care and developing community-clinical linkages in health centers serving North and West Philadelphia.

HFP Learning Collaborative

Year 1 Participating Health Centers

Delaware Valley Community Health Spectrum Health Services

2 SITES3+ SITES

Family Practice & Counseling Network

Esperanza Health Center

3 SITES 3 SITES

Reduce rates of death and disability due to diabetes, heart disease, and stroke

across Philadelphia.

Project Goals

Increase EHR adoption & use of HIT to improve performance

Increase institutionalization & monitoring of quality measures

Increase engagement of non-physician team staff in hypertension management

Increase self-measured blood pressure monitoring tied with clinical support

Strategies determined by CDC

Implement systems to identify pre-diabetes & undiagnosed hypertension

Increase engagement of CHWs to promote linkages between health systems and community resources for adults with high blood pressure, pre-diabetes or those at high risk

Increase engagement of community pharmacists in MTM for high blood pressure

Implement systems and increase partnerships to facilitate bidirectional referral between community resources and health systems, including lifestyle change programs

Strategies determined by CDC

Develop a clinical data dashboard for chronic disease measures (coordination with HCIF collaborative)

Implementation of tracking types for HTN, Diabetes, use of huddle sheets for pre-visit planning for these conditions.

Assessment of current practice, training, and adoption of best practices around setting, documenting and tracking self-management goals, and team-based care for HTN and diabetes.

Assessment of current practice and strategies developed for enhanced monitoring of medication adherence for chronic disease patients.

Health Center Activities for Year 1

Adoption of definition for pre-diabetes/undiagnosed hypertension, implement tracking types related to evidence based standard of care, and report.

Assessment of current practice, development of strategy around use of CHWs to link patients to care and community resources.

Assess, increase and track referrals to evidence-based community programs.

Health Center Activities for Year 1

• Provide expert technical assistance and training in chronic disease management, team-based care, EMR adaptations to support these, and data reporting.

• Ensure that data reporting is aligned with measures that health centers are reporting to other entities (CMS, HRSA, payers, etc.)

• With PDPH, leverage resources around medication therapy management, community health worker staff, self-monitoring programs and connections to evidence-based lifestyle change programs

• Provide an incentive of $15,000 per organization annually to help compensate for staff time spent on this project

Roles & Responsibility of Health Federation of

Philadelphia

• Designate a clinical leader as the main point of contact/participant in learning collaborative activities

• Allow/encourage clinical and support staff to participate in periodic training activities related to the collaborative (3-4 times per year)

• Provide input into a common dashboard of indicators related to hypertension and diabetes, and agree to report these on a monthly basis using EMR, i2i Tracks and/or Pop IQ

• Communicate regularly with HFP project staff on challenges and successes of project implementation

Roles & Responsibilities of Participating Health Centers

Health Centers’ number/percentage of adult patients with a diagnosis of:

o Diabetes - 6828 patientso Levels of control – 39% a1c >9 or no a1c

o Hypertension – 12,245 patientso Levels of control – 62.7% with BP <140/90

o Smoking - o Cessation counseling

Initial Measure Set

Pop IQ Trend Chart on Diabetes Control

Pop IQ Trend Chart on Hypertension Control

To run the report or check data definitions:

• On-site assessment of health center practice regarding chronic disease management:• Self-management goal setting and

documentation• Team-based care• Pre-visit planning• Community resources• Community Health Workers• Medication adherence

Next Steps

4th Thursday every two months?:March 26th, 2015 May 28th, 2015 July 23rd, 2015September 24th, 2015

(Conflict with HIV Care Network meetings)Or……

Future Collaborative Meetings

Questions/Discussion