CDC 1422 Grant: The Philly Difference, Connections for Better Chronic Care A Partnership with the Philadelphia Department of Public Health

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CDC 1422 Grant The Philly Difference,
Connections for Better Chronic CareA
Partnership with the Philadelphia Department of
Public Health
 

• Health Federation of Philadelphia
• www.healthfederation.org
• Funded by the Centers for Disease Control and
  Prevention, through the Philadelphia Department
  of Public Health

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HFP Learning Collaborative

• 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.

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Year 1 Participating Health Centers

• Delaware Valley Community Health

• Spectrum Health Services

3 SITES
2 SITES
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• Family Practice Counseling Network

• Esperanza Health Center

3 SITES
3 SITES
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Project Goals

• Reduce rates of death and disability due to
  diabetes, heart disease, and stroke across
  Philadelphia.

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Strategies determined by CDC

• 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

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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

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Health Center Activities for Year 1

• 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.

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Health Center Activities for Year 1

• Adoption of definition for pre-diabetes/undiagnose
  d 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.

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Roles Responsibility of Health Federation of
Philadelphia

• 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

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Roles Responsibilities of Participating Health
Centers

• 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

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Initial Measure Set

• Health Centers number/percentage of adult
  patients with a diagnosis of
• Diabetes - 6828 patients
• Levels of control 39 a1c gt9 or no a1c
• Hypertension 12,245 patients
• Levels of control 62.7 with BP lt140/90
• Smoking -
• Cessation counseling

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Pop IQ Trend Chart on Diabetes Control
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Pop IQ Trend Chart on Hypertension Control
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To run the report or check data definitions
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Next Steps

• 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

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Future Collaborative Meetings

• 4th Thursday every two months?
• March 26th, 2015
• May 28th, 2015
• July 23rd, 2015
• September 24th, 2015
• (Conflict with HIV Care Network meetings)
• Or

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Questions/Discussion