Transforming Diabetes Health Care Part 2. Changing Lives
|
|
- Elmer Lucas
- 5 years ago
- Views:
Transcription
1 In Brief Transforming Diabetes Health Care Part 2. Changing Lives Cindy Hupke, RN, BS, MBA; Anne W. Camp, MD; Roger Chaufournier, MHSA; Gerald J. Langley, MS; and Kevin Little, PhD The Health Disparities Collaboratives initiative of the Department of Health and Human Services Bureau of Primary Health Care (described in the article on p. 102) has allowed hundreds of health centers around the country to improve process and clinical outcomes for people with diabetes. This article reports on the results of these efforts from facilities participating in the collaboratives. Improving Outcomes Part 1 of this report on the diabetes efforts within the Health Disparities Collaboratives (HDCs) (p. 102) described how the Breakthrough Series model, 1 the Chronic Care Model, 2,3 and the Model for Improvement 4 were adapted in Bureau of Primary Health Care (BPHC) facilities to improve process and clinical outcomes in people with diabetes. The results of these efforts, from facilities participating in the collaboratives, are reported herein. As with any initiative, the proof is in the proverbial pudding, and the diabetes HDCs show impressive results. Each set of teams within each HDC has generated a plethora of data for the required and recommended measures. For this discussion, we will include only those teams that have just completed Phase 1 or are currently in Phase 2, as described in Part 1 of this report. One of the major paradigm shifts represented by the planned care model is the focus on managing an entire panel of patients, rather than individual patients. This shift requires tracking outcomes for the patient population and analyzing the needs of the population as a whole. The population is constantly changing, however, and the registry size fluctuates as new patients are added to the registry and others are removed due to death or relocation. Thus, the following process and outcome results are annotated with registry size statistics. The proportion of patients having two hemoglobin A 1c (A1C) tests within 12 months increased from 25% in March 1999 to 38% in July 2003, while the size of the registry increased by more than 24,000 patients. This was a relative improvement of 152%. During HDC 2000-Diabetes (HDC 2000-DM), the proportion of patients with two A1C tests within 12 months showed even greater improvement, with an increase from 18% in April 2000 to 38% in July 2003, while the size of the registry increased by almost 34,000 patients. This was a relative improvement of 211%. During the same HDC, the proportion of patients with documented self-management goal setting increased from 10% in February 2000 to 38% in July 2003, while the size of the registry increased by more than 63,000 patients. HDC 1999-Diabetes (HDC-1999-DM) participants also achieved a rate of 38% of patients having self-management goal setting, with 25,690 patients in the registry as of July The HDC 2001-Diabetes (HDC 2001-DM) showed an increase in documented self-management goal setting to almost 40%, while the registry grew from about 107
2 108 1,700 to more than 15,000 patients. During HDC 2001-DM, the proportion of patients with two A1C tests within 12 months increased from 14.1 to 31%, a relative improvement of 220%, while the size of the registry increased by more than 13,500 patients. The average A1C result decreased from 8.6 to 8.1% during this time frame. Results from HDC 2002-Diabetes (HDC 2002-DM) include more data, since additional measures were included to assess cardiac risk reduction: About 51% of more than 8,000 patients have documented selfmanagement goal setting. More than 37% of patients have had two A1C tests within 12 months. The average A1C is 7.98%. About 70% of patients over 55 years of age are taking angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. About 42% of patients over 40 years of age are taking statins. Individual health centers vary in the strength of their efforts and, consequently, in their results and success. What is clear from the HDCs results is that health centers of varying sizes, serving different patient populations in different regions of the country, have been able to achieve extraordinary results in improving the care of patients with diabetes. The following two case studies illustrate how individual health centers used HDC participation to facilitate remarkable change in health outcomes and in the delivery of health services. Fair Haven: Formalizing and Expanding Progress The Fair Haven Community Health Center (FHCHC) has served a New Haven, Conn., inner-city neighborhood for more than 30 years. The center provides the only primary care in the area for approximately 11,000 patients through its main clinic, three school-based health centers, and a satellite clinic in an elderly housing complex. The patient base reflects the community, with minorities comprising 84% of patients, 65% percent of whom are Latino, and 19% of whom are African American. Like most community health centers, FHCHC serves patients at high risk for diabetes and poor diabetes outcomes. About 35% of the health center s patients with diabetes have no medical insurance and thus no means to afford the $800 1,000 monthly costs for pharmacy products, blood tests, and glucose monitoring supplies. Forty percent of patients speak little or no English, and a growing percentage are undocumented immigrants. The neighborhood has few safe places to walk or exercise and lacks markets with affordable, fresh, low-calorie foods. Diabetes was recognized as an important and growing problem at the health center several years ago. A few providers formed a team to promote diabetes education, self-management efforts, and community awareness. The team supported improvement in the management of the diabetes population through provider education and improved standards of diabetes care. Diabetes flow sheets were used in patients charts; formal treatment policies and recommendations aligned with the American Diabetes Association (ADA) standards of care were adopted. The team assessed overall care delivery by periodic chart reviews and anecdote. However, they recognized the need to more systematically identify patient groups in need of care and knew that their improvement efforts suffered from an inability to measure performance and progress in meeting treatment goals for patients. In 2000, FHCHC first participated in the intensive work of improving care for diabetes with the HDC and was provided with a patient registry/database (described in Part 1 of this report). This was the very tool they had wished for to fuel their progress. The care model (also described in Part 1) gave the team a formal framework to describe and expand upon work they were already doing; the improvement model (also described in Part 1) helped them to focus on small rapid change cycles to improve care. With the patient registry as a tool, FHCHC has been able to work on chronic care delivery with a real time database. The team developed systems using the registry to provide up-to-date patient information and patient trend information, making patient visits more efficient and helping providers better plan care. They have used the registry to extend the delivery system to include other members of the care team, thus allocating responsibility for the multiple aspects of diabetes care. For example, the registry-generated encounter note automatically prompts medical assistants to perform an in-office A1C test if one is due and prompts nurses to provide influenza and pneumococcal vaccines if they are needed. Furthermore, the health center not only has up-to-date information on and reminders about individual patients, but also can use this information to better manage diabetes care for groups of patients or for their entire population. So, for example, when the rare opportunity of a local smoking cessation program in Spanish became available, the team rapidly generated a report of patients with diabetes who smoked and spoke Spanish. They contacted patients individually and encouraged them to participate at the invitation of their provider. As another example, each November, staff members run reports to identify patients who have not yet received influenza vaccinations. These patients are then contacted through letters or phone call reminders and scheduled for appointments. The changes made by FHCHC led to improvements in process and outcome measures. Figure 1 shows some of the results FHCHC achieved during Phase 1 of the HDC. Several of the graphs include a dashed line representing the goal for that measure. As the FHCHC team entered Phase 2 of the HDC, it faced the challenge of spreading change to new providers, patients, and new conditions while sustaining changes and continuing improvement. The team used the registry and the information and skills learned during Phase 1 to better implement changes for more providers and patients during Phase 2. For example, in Phase 1, the team included cardiovascular risk reduction measures and lipid management among its goals. It set a demanding target: 70% of patients with diabetes will achieve an LDL cholesterol level < 100 mg/dl, which was more ambitious than the HDC proposed goal (LDL cholesterol < 130 mg/dl). Using the patient registry, the team members discovered that the lipid-screening rate was only 70% and that just 30% of patients screened had LDL cholesterol levels < 100 mg/dl. The team then ran reports identifying patients who had not been screened and those whose LDL choles-
3 Figure 1. FHCHC population of focus, year 1. terol level was > 100 mg/dl. Using these reports, they performed a targeted chart review to identify reasons for poor lipid management. They had predicted that lack of health insurance would be the major factor in poor management, but it found that provider omission and data inaccuracy were equally significant. Armed with this information, the team focused its Diabetes Spectrum Volume 17, Number 2, 2004 CareSouth Carolina: Making the Business Case for Quality In addition to improving process and outcome measures, there is emerging evidence that involvement in an HDC saves money. As shown in Table 2, benchmark data from the South Carolina State Budget and Control Board have documented lower rates of hospitalization, shorter lengths of stay per admission, and significant cost savings for health centers trained in planned care through an HDC, compared with those uninitiated to planned care and other providers. Although most of the health centers participating in the HDCs focused on diabetes, the crucial elements for better care are similar for all chronic conditions and preventive services. Health centers throughout the country have used the care model to improve treatment of other chronic illnesses or comorbidities, such as cardiovascular disease, depression, and asthma, and are currently piloting use of the care model for prevention activities. Through partnerships with the Centers for Disease Control and Prevention, the Institute for Healthcare Improvement, the National Institute of Diabetes and Digestive and Kidney Diseases, and the Medstar Clinical Research Center, sim- efforts on these areas, working to improve access of uninsured patients to testing and medications, update providers on current standards of care for lipid control, and improve data accuracy. In addition, the team used the reports to create a treatment and follow-up plan for individual patients and to provide feedback to providers about their patients. Table 1 lists examples of specific changes the health center made in the different components of the care model during Phase 2. Using the patient registry, FHCHC reexamines data continuously and closely follows clinical improvements. Figure 2 shows the rates of lipid screening and achievement of LDL cholesterol goals among 600 Fair Haven registry patients with diabetes. Despite increasing enrollment in the registry, the percentage of patients screened for hyperlipidemia (currently about 80%) and achieving the LDL cholesterol goal of < 100 mg/dl (currently > 50%) continue to increase. The ongoing improvement demonstrates the effectiveness of quality improvement efforts to meet the needs of people with diabetes. 109
4 Table 1. Changes Made by Fair Haven Community Health Center Delivery system Developed a voucher system to use donations and grants to pay for ongoing lipid lab work for uninsured patients Created pull lists of patients due for annual lipid profile or not meeting treatment goals to ensure medical follow-up Created system for contacting patients to schedule needed labs and follow-up independent of provider visit Clinical information Strengthened lab reporting/data interface to ensure more accurate data systems Performed regular analysis of missing labs and patients overdue for care Decision support Sponsored continuing education for providers on lipid management Generated automatic patient-specific reminders at the time of the patient encounter, if patient not meeting goals Generated monthly reports to individual providers on all aspects of diabetes care, including lipid management Self-management Obtained more language- and literacy level appropriate teaching materials Offered free lipid-screening day with classes for patients Sent periodic reminders to patients due for follow-up Health care organization Strengthened pharmaceutical assistance program for uninsured patients to more proactively manage ordering of patients medications in a timely fashion Community Obtained educational grants from pharmaceutical companies to support patient education programs Worked with state diabetes control program for funds to provide vouchers for free fruits and vegetables at local supermarket Sponsored weekly walking club for patients Sponsored event at neighborhood restaurant with new low-fat items on menu Figure 2. Rates of lipid screening and achieving LDL goal of < 100 mg/dl among Fair Haven Community Health Center patients. POF, population of focus (patients included in Phase 1 and Phase 2 efforts); spread, patients included in Phase 2 efforts only. 110 Diabetes Spectrum Volume 17, Number 2, 2004
5 ilar methods are being applied to other conditions in other communities, translating the results of the Diabetes Prevention Program 5 into widespread clinical practice. The process of changing to a planned care approach can be both time-consuming and difficult, but the results are rewarding. By integrating sound management and business practices with the components of the care model described in Part 1 of our report, organizations can demonstrate a business case for health care improvement. Health care leaders and providers need to seize the opportunity to align their work in the organization and thus reduce cost, improve productivity, and enhance revenue, while improving clinical quality and patient satisfaction. Acknowledgment It is through the vision and leadership of David M. Stevens, MD, FAAF, that the HDCs were crafted. Dr. Stevens and Tricia Trinite, NP, MSPH, have provided ongoing national leadership and guidance from the BPHC for the HDCs and have been integral in the development of strong partnerships with the Institute for Healthcare Improvement Table 2. CareSouth Carolina Data Profile* CHC trained in CHC uninitiated to Other community Specialists planned care planned care providers Average patient age (years) Average office visits per patient Percentage of patients having >1 office visit (%) Average number of days between office visits Percentage of patients with a hospitalization (%) Average payment per inpatient $3, $39, $10, $12, Average length of stay (days) Average payment per $67.42 $66.55 $65.52 $67.35 office visit Average total annual cost $ $4, $1, $1, *Data based on records of South Carolina State Budget and Control Board for state health plan claims for the period from January 1, 2000, to December 31, 2001, for patients with diabetes as a primary or secondary diagnosis. CHC, community health center ( Improving Chronic Illness Care ( and the Centers for Disease Control and Prevention Division of Diabetes Translation ( diabetes). References 1 Baker GR: Collaborating for improvement: the Institute for Healthcare Improvement s Breakthrough Series. New Med 1:5 8, Bodenheimer T, Wagner EH, Grumbach K: Improving primary care for patients with chronic illness. JAMA 288: , Bodenheimer T, Wagner EH, Grumbach K: Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 288: , Langley J, Nolan K, Nolan T, Norman C, Provost L: The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, Jossey-Bass, The DPP Research Group: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346: , 2002 Cindy Hupke, RN, BS, MBA, lives in DeKalb, Ill., and is the IHI s national director for the BPHC HDCs. Anne W. Camp, MD, is an internist and endocrinologist at the Fair Haven Community Center and a clinical instructor of medicine at the Yale School of Medicine in New Haven, Conn. Roger Chaufournier, MHSA, is president and chief executive officer of Patient Infosystems in Rochester, NY, and serves on the faculty of Johns Hopkins University School of Public Health in Bethesda, Md. Gerald J. Langley, MS, is a statistician with Associates in Process Improvement in Cameron Park, Calif., and senior improvement advisor for the BPHC HDCs. Kevin Little, PhD, is a statistician based in Madison, Wisc., and serves as a BPHC collaboratives technical advisor. Note of disclosure: The authors are all paid consultants for the HDCs described in this article. Mr. Chaufournier is an employee and board member of Patient Infosystems, which provides disease management services for the health care industry, including the federal government. He is also a stock shareholder in Patient Infosystems, Pharmacia, and Solutia, all of which make products or provide services related to the treatment of diabetes. 111
Your Partnership in Health Report: Chronic Conditions ABC Company and Kaiser Permanente
Your Partnership in Health Report: s ABC Company and Kaiser Permanente Measurement Period: JUL-01-2012 through JUN-30-2013 Report Date: DEC-31-2013 Commercial All Members Partnership in Health (PIH) reports:
More informationKey Elements in Managing Diabetes
Key Elements in Managing Diabetes Presentor Disclosure No conflicts of interest to disclose Presented by Susan Cotey, RN, CDE Lennon Diabetes Center Stephanie Tubbs Jones Health Center Cleveland Clinic
More informationQUALITY IMPROVEMENT TOOLS
QUALITY IMPROVEMENT TOOLS QUALITY IMPROVEMENT TOOLS The goal of this section is to build the capacity of quality improvement staff to implement proven strategies and techniques within their health care
More informationEngaging patients and providers with the right information, at the right time, to do the right thing
Engaging patients and providers with the right information, at the right time, to do the right thing Using Automated Patient Engagement and Clinical Decision Support tools to Improve Outcomes and Reduce
More informationRiding the Current: Upstream and Downstream Approaches to Implement Adult Immunization Strategies
Riding the Current: Upstream and Downstream Approaches to Implement Adult Immunization Strategies Paul Nguyen Community Health Partnership Connie Chung-Bohling California Department of Public Health Session
More informationHealth Insurance Plans Approaches to Asthma Management: 2006 Assessment
America s Health Insurance Plans Health Insurance Plans Approaches to Asthma Management: 2006 Assessment Supported through a cooperative agreement with the United States Environmental Protection Agency
More informationPatient Activation + Engagement: Implementing Diabetes Group Appointments
Patient Activation + Engagement: Implementing Diabetes Group Appointments Janelle Howe, Director, Disease Management Aurora Galindo Simental, Health Educator June 20, 2013 Solutions-Oriented Approaches
More informationThe Journey towards Total Wellbeing A Health System s Innovative Approach
The Journey towards Total Wellbeing A Health System s Innovative Approach Company Profile Wellness A state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity
More informationQuality Improvement Methodology, Workflow Redesign and Outcomes Management
Quality Improvement Methodology, Workflow Redesign and Outcomes Management Jeffrey Hummel, MD, MPH Medical Director for Clinical Informatics, Qualis Health and UW Medicine Neighborhood Clinics July 28,
More informationIntegrated Health Care Services
Integrated Health Care Services Integrated Health Care Services Programs with integrated health care services achieve the strongest results. Strategies for creating integrated care systems include: Educating
More informationRUSH OAK PARK HOSPITAL. FY14 FY16 Implementation Strategy
RUSH OAK PARK HOSPITAL FY14 FY16 Implementation Strategy Introduction For more than 100 years, Rush Oak Park Hospital has been dedicated to providing exceptional and compassionate health care to its surrounding
More information2017 Wellness Program Guide. East Central College
2017 Wellness Program Guide East Central College CHC Wellness and East Central College know the importance of a healthy lifestyle. When you live healthy, you live happy. That is why we are partnering together
More informationLifestyle, Evaluation, & Counseling. 10:15 am Panel Anne Marie Navar, MD, PhD
Lifestyle, Evaluation, & Counseling 10:15 am Panel Anne Marie Navar, MD, PhD Lifestyle Management Martha L. Daviglus, MD, PhD, FAHA Edmund Foley Professor of Medicine University of Illinois at Chicago
More informationDisclosure Statement
Part 5 PROMOTING NUTRITIONAL HEALTH AND DIABETES PREVENTION Presented by: Katherine Brieger, RD and Elizabeth Magenheimer, MSN, APRN,CNM Disclosure Statement Faculty: Katherine Brieger, RD and Elizabeth
More informationThe Role of Health Information Technology in Implementing Disease Management Programs
The Role of Health Information Technology in Implementing Disease Management Programs Donald F. Wilson, MD Medical Director Quality Insights of Pennsylvania May 11, 2006 Statewide Combined Topic Average
More informationHigh-quality diabetes care can
Development and Evolution of a Primary Care Based Diabetes Disease Management Program Robb Malone, PharmD, CDE, CPP; Betsy Bryant Shilliday, PharmD, CDE, CPP; Timothy J. Ives, PharmD, MPH; and Michael
More informationInvesting in Diabetes Prevention The National Diabetes Prevention Program and ROI as a covered benefit
Investing in Diabetes Prevention The National Diabetes Prevention Program and ROI as a covered benefit Shannon Haffey, Director of Value Based Benefit & Reimbursement February 2016 Objectives Learn the
More informationMary Ann Hodorowicz RDN, MBA, CDE, CEC (Certified
Mary Ann Hodorowicz RDN, MBA, CDE, CEC (Certified Endocrinology Coder) Mary Ann Hodorowicz, RDN, MBA, CDE, CEC, is a licensed registered dietitian and certified diabetes educator and earned her MBA with
More informationCamden Citywide Diabetes Collaborative
Camden Citywide Diabetes Collaborative The Camden Coalition of Healthcare Providers is an organization that seeks to improve the quality, capacity and accessibility of the health care system for vulnerable,
More information2017 Diabetes. Program Evaluation. Our mission is to improve the health and quality of life of our members
2017 Diabetes Program Evaluation Our mission is to improve the health and quality of life of our members Diabetes Program Evaluation Program Title: Diabetes Program Evaluation Period: January 1, 2017 December
More informationWorking Together to Prevent Diabetes
Working Together to Prevent Diabetes Elizabeth Joy, MD, MPH, FACSM Medical Director, Community Health Food & Nutrition Family Medicine / Sports Medicine Salt Lake Clinic 29.1 million Americans have diabetes
More informationMEASURES AND QUALITY IMPROVEMENT
MEASURES AND QUALITY IMPROVEMENT CO-LOCATION OF PRIMARY CARE AND BEHAVIORAL HEALTH Date: August 15, 2017 Introduction Today s Presenter Jacqueline Delmont, MD, MBA Delmont Healthcare Grassi & Co. General
More informationTools for Targeting High Risk Patients in Your Practice. Statement of Disclosure
Tools for Targeting High Risk Patients in Your Practice Joseph Vande Griend, PharmD, BCPS, CGP Assistant Professor, University of Colorado Departments of Clinical Pharmacy and Family Medicine Skaggs School
More informationDUPLICATION DISTRIBUTION PROHIBBITED AND. Utilizing Economic and Clinical Outcomes to Eliminate Health Disparities and Improve Health Equity
General Session IV Utilizing Economic and Clinical Outcomes to Eliminate Health Disparities and Improve Health Equity Accreditation UAN 0024-0000-12-012-L04-P Participation in this activity earns 2.0 contact
More informationHEALTHCARE REFORM. September 2012
HEALTHCARE REFORM Accountable Care Organizations: ACOs 101 September 2012 The enclosed slides are intended to provide you with a general overview of accountable care organizations (ACOs), created within
More informationSuccessful Implementation of Diabetes Self- Management Education [DSME] in your Community Health Center
Successful Implementation of Diabetes Self- Management Education [DSME] in your Community Health Center Bonnie Hollopeter, LPN, CPHQ, CPEHR State Quality Improvement Lead, Health Services Advisory Group
More informationREVIEW AND FREQUENTLY ASKED QUESTIONS (FAQ) 8/5/2015. Outline. Navigating the DSMT Reimbursement Maze in Todays Changing Environment
Patty Telgener RN, MBA, CPC VP of Reimbursement Emerson Consultants Navigating the DSMT Reimbursement Maze in Todays Changing Environment Patty Telgener, RN, MBA, CPC VP of Reimbursement Emerson Consultants
More informationImproving Diabetes Quality of Care in Your Practice. Successful Diabetes Practices in New Mexico Clinics
Improving Diabetes Quality of Care in Your Practice Introduction According to the American College of Physicians (ACP), high quality diabetes care requires a systematic and organized team-based approach.
More informationEffectiveness of Primary Care Interventions to Address Childhood Obesity. Disclosure and Presentation Support 11/22/16
Effectiveness of Primary Care Interventions to Address Childhood Obesity A Review and Directions for the Future Session III: Supporting and Promoting Involvement Diane Dooley, M.D., M.H.S. Co- authors:
More informationMichigan Oncology Quality Consortium. Jeffrey Smerage, MD, PhD Physician Lead Jane Severson, RN, MHSA Project Manager
Michigan Oncology Quality Consortium Jeffrey Smerage, MD, PhD Physician Lead Jane Severson, RN, MHSA Project Manager I. MOQC Overview MOQC is the BCBSM coordinating center for practices participating in
More informationSuccesses in Regional Collaboration to Achieve the Triple Aim Oregon. Pay for Performance Summit San Francisco March 24, 2014
Successes in Regional Collaboration to Achieve the Triple Aim Oregon Pay for Performance Summit San Francisco March 24, 2014 Agenda Oregon Health Care Quality Corporation (Q Corp) Background Priority Projects
More informationThe Burden of Kidney Disease in Rural & Northern Ontario
Ontario Branch The Burden of Kidney Disease in Rural & Northern Ontario Contact: Janet Bick Director, Policy & Programs The Kidney Foundation of Canada Ontario Branch Tel: 905-278-3003/1.800-387-4474 ext.4970
More informationMonthly Campaign Webinar. May 19, 2016
Monthly Campaign Webinar May 19, 2016 WEBINAR REMINDERS Webinar will be recorded today and available the week of May 23 rd Together2Goal.org Website (Improve Patient Outcomes Webinars) Email distribution
More informationKAISER PERMANENTE OF GEORGIA COMMUNITY BENEFIT REPORT
2016 KAISER PERMANENTE OF GEORGIA COMMUNITY BENEFIT REPORT Partnering to Build Healthy Communities At Kaiser Permanente Georgia, our commitment to improving health has been going strong for more than 30
More informationThe Prevention of Type 2 Diabetes: From Theory to Practice
The Prevention of Type 2 Diabetes: From Theory to Practice David G Marrero, Ph.D. J.O. Ritchey Professor of Medicine Diabetes Translational Research Center Indiana University School of Medicine Diabetes:
More informationCity of Berkeley CSS Plan Revised Budget Narratives. Full Service Partnership Integrated Services Expansion for TAY, Adults and Older Adults
City of Berkeley CSS Plan Revised Budget Narratives The additional funds provided by the CSS expansion have been added into the previously approved 07/08 budgets. What follows are the revised budget narratives
More informationEnsure access to and compliance with treatment for low-income uninsured Virginia residents living with HIV/AIDS
Public Health/ CHSB Lilibeth Grandas x1211 Sharron Martin x1239 Program Purpose Program Information Ensure access to and compliance with treatment for low-income uninsured Virginia residents living with
More informationCHC TOBACCO CESSATION PROGRAM SCOPE OF WORK
CHC TOBACCO CESSATION PROGRAM SCOPE OF WORK Goal 1: Develop a Tobacco Cessation Program focused on evidenced-based clinical guidelines that is seamlessly integrated in CHC's care processes. Strategy 1-1:
More informationUncertainty with and timing of funding with next CDC FOA. Collaboration
Table 2: Summary of overarching policy, systems and environmental priorities and planned action steps during the summit and reported stages of change, successes and challenges six months later by Region
More informationParticipants in the Program
Type 2 Diabetes Performance Improvement Initiative: Chart Reviews Participants in the Program 318 clinicians have registered 192 have started the program 126 have started their initial chart review 26
More informationPUTTING OUT THE ADDICTION:
PUTTING OUT THE ADDICTION: Tobacco Cessation and Prevention Programs INDUSTRY PULSE FROM THE HEALTHCARE INTELLIGENCE NETWORK TM White paper analysis of HIN monthly e-survey results on trends shaping the
More informationIdeas + Action for a Better City learn more at SPUR.org. tweet about this #FoodisMedicine
Ideas + Action for a Better City learn more at SPUR.org tweet about this event: @SPUR_Urbanist #FoodisMedicine Food is Medicine SPUR February 12, 2019 Rita Nguyen, MD Assistant Health Officer Chronic Disease
More informationCOMMUNITY HEALTH NEEDS ASSESSMENT IMPLEMENTATION STRATEGY
2016 COMMUNITY HEALTH NEEDS ASSESSMENT IMPLEMENTATION STRATEGY Table of Contents Introduction... 2 Executive summary... 2 University Care System s mission, vision, and values... 2 Description of the health
More informationWorking Together to Prevent Diabetes
Elizabeth Joy, MD, MPH Intermountain Healthcare Medical Director, Community Health & Clinical Nutrition President, American College of Sports Medicine Working Together to Prevent Diabetes Overview Why
More informationQuality Data for Beginners Using your Electronic Medical Record for Quality Reporting and Better Patient Care
Using your Electronic Medical Record for Quality Reporting and Better Patient Care Developed by HealthInsight with funding from the U.S. Centers for Disease Control and Prevention through the Utah Department
More informationRandolph County. State of the County Health Report 2014
Randolph County State of the County Health Report 2014 Inside this issue: Priority Areas 2-4 Overweight and Obesity Data 5 Physical Activity 6 Substance Abuse 7 Access to Care 8 Morbidity and Mortality
More informationRoutinizing HIV and HCV Testing Using an Innovative, Scalable and Sustainable Dual Testing Model
Routinizing HIV and HCV Testing Using an Innovative, Scalable and Sustainable Dual Testing Model Catelyn Coyle MPH, MEd Public Health National Symposium June 2014 Outline Background Description of model
More informationStrategy at Work. MedStar Health. Engaging people, improving performance
Strategy at Work MedStar Health Engaging people, improving performance About MedStar Health A $3.1 billion nonprofit health care organization formed in 1998 Headquartered in Columbia, MD Operates eight
More informationCreating Policy to Promote and Support Individual Change. Ann Albright, PhD, RD
Creating Policy to Promote and Support Individual Change Ann Albright, PhD, RD Director, Division of Diabetes Translation Centers for Disease Control and Prevention The findings and conclusions in this
More informationImproving Diabetes Care A Roadmap to Better Chronic Care
Improving Diabetes Care A Roadmap to Better Chronic Care Robert A. Gabbay, MD, PhD, FACP Chief Medical Officer Joslin Diabetes Center Harvard Medical School TODAY Diabetes as a Target Disease Patient Centered
More informationSafety Net Medical Home Initiative: Transforming Practices into Medical Homes
Safety Net Medical Home Initiative: Transforming Practices into Medical Homes PCI Pt. 2: Self-Management Support in the PCMH Moderated by: Nicole Van Borkulo, MEd, Quality Improvement Consultant, Qualis
More informationTogether 2 Goal Innovator Track: Cardiovascular Disease Cohort. Call for Participation
Together 2 Goal Innovator Track: Cardiovascular Disease Cohort Call for Participation Cardiovascular Disease (CVD) and Diabetes Approximately 28 million Americans are living with Type 2 diabetes. Due to
More informationMaster the Metrics that Matter. A dentist s guide to managing key performance indicators (KPIs) for greater productivity and efficiency.
Master the Metrics that Matter A dentist s guide to managing key performance indicators (KPIs) for greater productivity and efficiency. About the Author Tammy McHood is a senior product manager for Henry
More informationPriority Area: 1 Access to Oral Health Care
If you are unable to attend one of the CHARTING THE COURSE: Developing the Roadmap to Advance Oral Health in New Hampshire meetings but would like to inform the Coalition of activities and services provided
More informationBaptist Health Jacksonville Community Health Needs Assessment Implementation Plans. Health Disparities. Preventive Health Care.
Baptist Health Jacksonville Community Health Needs Assessment Implementation Plans Health Disparities Infant Mortality Prostate Cancer Heart Disease and Stroke Hypertension Diabetes Behavioral Health Preventive
More informationMonitoring non compliant diabetic A1C levels
The University of San Francisco USF Scholarship: a digital repository @ Gleeson Library Geschke Center Master's Projects and Capstones Theses, Dissertations, Capstones and Projects Summer 8-17-2015 Monitoring
More informationProject LIM Lifestyle Interventions Matter
Executive Summary Project LIM Lifestyle Interventions Matter Project LIM (Lifestyles Interventions Matter) will focus on lifestyle modification to reduce the risk factors for prediabetes and ultimately
More informationExecutive Director s. Update
Executive Director s Update February 2013 Mission, Vision and Values Toastmasters International Mission Vision Values Toastmasters International s core values are integrity, dedication to excellence,
More informationPractical Predictive Analytics. John Cuddeback, MD, PhD AMA IPPS November 11, 2016
Practical Predictive Analytics John Cuddeback, MD, PhD AMA IPPS November 11, 2016 AMGA s Work in Analytics Advocacy: Align payment incentives around population health Programs: Help members redesign delivery
More informationBaptist Health Beaches Community Health Needs Assessment Priorities Implementation Plans
Baptist Health Beaches Community Health Needs Assessment Priorities Implementation Plans Health Disparities Heart Disease Stroke Hypertension Diabetes Adult Type II Preventive Health Care Smoking and Smokeless
More informationLinking Public Interests to Ensure Sustainable Statewide Quitlines
Linking Public Interests to Ensure Sustainable Statewide Quitlines Public health tobacco prevention and control programs (TCPs) find themselves working within evershifting financial and political landscapes,
More informationMedicare Shared Savings Program Quality Measure Benchmarks for the 2014 and 2015 Reporting Years
Medicare Shared Savings Program Quality Measure Benchmarks for the 2014 and 2015 Reporting Years Introduction This document describes methods for calculating the quality performance benchmarks for Accountable
More informationWill California s Health Care Reform Make Californians Healthier?
Will California s Health Care Reform Make Californians Healthier? E. Richard Brown, PhD Director, UCLA Center for Health Policy Research Professor, UCLA School of Public Health Council of State Governments
More informationAbout this consent form
Protocol Title: Development of the smoking cessation app Smiling instead of Smoking Principal Investigator: Bettina B. Hoeppner, Ph.D. Site Principal Investigator: n/a Description of Subject Population:
More informationWhittier Street Health Center Diabetes Care Coordination Program
Whittier Street Health Center Diabetes Care Coordination Program PROJECT OVERVIEW Whittier Street Health Center (WSHC) is a Federally Qualified Health Center (FQHC) located in Boston, Massachusetts. The
More informationPartnering to End Hunger in the Grand Valley
Partnering to End Hunger in the Grand Valley Takeaways Food security is a real issue for Mesa County There is a statewide effort to address food security called the Colorado Blueprint to End Hunger Mesa
More informationGreater Rochester, NY Chapter #314 Enhancing the success of women in the construction industry in Rochester since 1985
Greater Rochester, NY Chapter #314 Enhancing the success of women in the construction industry in Rochester since 1985 MEMBER RETENTION FOR THE NATIONAL ASSOCIATION OF WOMEN IN CONSTRUCTION (NAWIC) PREPARED
More informationMobile Health, Community Health Workers, or Both for the Care of Type 2 Diabetes Patients with Medicaid
365-OR Mobile Health, Community Health Workers, or Both for the Care of Type 2 Diabetes Patients with Medicaid Michelle Magee, MD MedStar Health Diabetes, Research & Innovation Institutes Georgetown University
More informationHEALTHY LIVING: Strategies, Programs and Practices Being Scaled by Y-USA
HEALTHY LIVING: Strategies, Programs and Practices Being Scaled by Y-USA Matt Longjohn MD MPH National Health Officer YMCA of the USA THIS DECK 1. INTRODUCE THE Y S APPROACH TO HEALTHY LIVING 2. SHARE
More informationRheumatoid Arthritis Learning Collaborative
Add your company logo Add here your company logo here Rheumatoid Arthritis Learning Collaborative Sponsored by AMGF and AbbVie June 11, 2015 Group Update Sutter Medical Group of the Redwoods/Sutter Pacific
More informationProject Title Community Pharmacy Participation in Health Screening and Medication Therapy Management
Project Title Community Pharmacy Participation in Health Screening and Medication Therapy Management Author and Location Sahar M.Rashed, Ph.D, Pharm.D (srashed@utmem.edu) Associate Professor of Clinical
More informationMel5369 Project 3 December 5, Strong Bones, Strong Body A Program for Older Adults
Strong Bones, Strong Body A Program for Older Adults 1. The targeted nutrition need that will be the focus of this program is the importance of calcium, vitamin D, and physical activity for osteoporosis
More informationTitle & Subtitle can knockout of image
Title & Subtitle can knockout of image LARGE OPENING IMAGE HERE 50 accc-cancer.org July August 2016 OI BY PATRICIA INAMA RODA, MSN, BS, RN, AND JAIME FRITCHMAN, BS A Community Comes Together to Help Patients
More informationInstructor s Guide. Building Healthier Communities. Introduction T
Building Healthier Communities Instructor s Guide Introduction T his instructor s guide is designed to provide you with helpful suggestions collected from a wide range of congregational health programs
More informationDennis P. Scanlon, Ph.D. Jeff Beich, Ph.D. Patti Simino Boyce RN, Ph.D. AcademyHealth, June 30, 2009
Dennis P. Scanlon, Ph.D. Jeff Beich, Ph.D. Patti Simino Boyce RN, Ph.D. AcademyHealth, June 30, 2009 Many policymakers and stakeholder organizations have suggested the need for sustainable community level
More informationChronic Obstructive Learning Collaborative Sponsored by AMGA and Boehringer Ingelheim Pharmaceuticals, Inc.
Chronic Obstructive Learning Collaborative Sponsored by AMGA and Boehringer Ingelheim Pharmaceuticals, Inc. November 2-4, 2011 San Antonio, Texas University of Michigan Faculty Group Practice Improving
More informationSIGN LANGUAGE INTERPRETER Job Description
CATEGORY: INSTRUCTIONAL SUPPORT POSITION STATUS: FULL-TIME FLSA STATUS: NON-EXEMPT SALARY CODE: 52 The incumbent in this job is expected to assist the College in achieving its vision and mission of student
More informationMercy Diabetes Prevention Program
Mercy Diabetes Prevention Program Know the risk. Make the change. Live your life. Ashton Caton, Community Wellness Program Manager May 11, 2018 The Statistics DIABETES 30.3 million Americans People who
More informationAdventist HealthCare Washington Adventist Hospital Community Health Needs Assessment Implementation Strategy. Adopted May 15, 2017
Adventist HealthCare Washington Adventist Hospital 2017-2019 Community Health Needs Assessment Implementation Strategy Adopted May 15, 2017 Implementation Strategy Development & Adoption Adventist HealthCare
More informationEffectiveness of a Multidisciplinary Patient Assistance Program in Diabetes Care
University of Rhode Island DigitalCommons@URI Senior Honors Projects Honors Program at the University of Rhode Island 2009 Effectiveness of a Multidisciplinary Patient Assistance Program in Diabetes Care
More informationAddressing the Problem of Health Literacy: Practical Approaches in Practice
Addressing the Problem of Health Literacy: Practical Approaches in Practice Darren DeWalt, MD, MPH & Michael Pignone, MD, MPH University of North Carolina-Chapel Hill Department of Medicine Topics Relationship
More informationWhat Does Walt Disney Have To Do With Heath Care: The Importance of Quality, Reliability, and Engaged Physicians
What Does Walt Disney Have To Do With Heath Care: The Importance of Quality, Reliability, and Engaged Physicians Scott Hines, MD Chief Quality Officer Crystal Run Healthcare October 22, 2015 Learning Objectives
More informationLead the Way with Advanced Care Management. Workbook
Lead the Way with Advanced Care Management Workbook TPCA Training 10.2018 Section 1: Using i2itracks for Chronic Disease Management Chronic Disease Tracking in 2018 Disease Management Definition A system
More informationCelebremos La Vida! Midwest Style A collaboration between the Family Health Partnership Clinic and the Prevent Cancer Foundation
Celebremos La Vida! Midwest Style A collaboration between the Family Health Partnership Clinic and the Prevent Cancer Foundation Prepared for: The Sixth National Conference on Quality Health Care for Culturally
More informationUNIVERSITY OF CHICAGO MEDICINE & INSTITUTE FOR TRANSLATIONAL MEDICINE COMMUNITY BENEFIT FY 2016 ADULT DIABETES GRANT GUIDELINES
UNIVERSITY OF CHICAGO MEDICINE & INSTITUTE FOR TRANSLATIONAL MEDICINE COMMUNITY BENEFIT FY 2016 ADULT DIABETES GRANT GUIDELINES The following grant guidelines will help you prepare your grant proposal
More informationThis product was developed by the Proyecto Vida Saludable at the Holyoke Health Center, Inc. in Holyoke, MA. Support for this product was provided by
This product was developed by the Proyecto Vida Saludable at the Holyoke Health Center, Inc. in Holyoke, MA. Support for this product was provided by a grant from the Robert Wood Johnson Foundation in
More information5 HEALTH PRIORITIES, 10 OUTCOME MEASURES
Community Health Needs Assessment 217-219 5 HEALTH PRIORITIES, 1 OUTCOME MEASURES improving the health of our community in all we do 217 progress Report 217 218 219 ased on a comprehensive community needs
More informationUsing Analytics for Value-Based Care
Using Analytics for Value-Based Care John Cuddeback, MD, PhD Elizabeth Ciemins, PhD, MPH, MA AMGA Northwest Regional Meeting February 3, 2017 Seattle A Fundamental Change Is Underway Fee for Service MIPS
More informationSTRATEGIES FORPREVENTION AND CONTROL OFDIABETES. Marti Macchi, MEd, MPH Senior Consultant National Association of Chronic Disease Directors
STRATEGIES FORPREVENTION AND CONTROL OFDIABETES Marti Macchi, MEd, MPH Senior Consultant National Association of Chronic Disease Directors National Association of Chronic Disease Directors National public
More informationThe SEVEN TOUCHES PROGRAM
The SEVEN TOUCHES PROGRAM Connects you to success National Association of Insurance and Financial Advisors Background: the seven touches The Seven Touches of Membership (Seven Touches) is based on a study
More informationMEASUREMENT FOR IMPROVEMENT. Pat Waniewski, RN, MS
MEASUREMENT FOR IMPROVEMENT Pat Waniewski, RN, MS In God we trust. All others bring data. W. E. Deming Learning Objectives Identify the purpose and general principles of measurement for quality improvement
More informationGood Health Is Good Business
Good Health Is Good Business Statistical Analysis for San Joaquin Valley Insurance Authority - 2012 Health Evaluations Report created on March 16, 2012 Quality Survey Results Was the blood drawer courteous?
More informationCancer Screening Program
Cancer Screening Program Mountain Park Health Center/Mayo Clinic Collaboration Region IX Management Training Conference November 11 th, 2008 Mountain Park Health Center! Founded in 1980! Services: Pediatrics,
More informationPrimary Care Pharmacist Integration and Reimbursement Models
Primary Care Pharmacist Integration and Reimbursement Models May 20, 2015 MODERATOR: Marie Smith, PharmD Palmer Professor and Assistant Dean, Practice and Public Policy Partnerships, UConn School of Pharmacy
More informationA Decade of Data: Findings and Insights from the National Palliative Care Registry
A Decade of Data: Findings and Insights from the National Palliative Care Registry Maggie Rogers, MPH Senior Research Manager, CAPC Rachael Heitner, MA, CHPCA Research Associate, CAPC July 19, 2018 at
More informationCardiometabolic Disorder and Diabetes Management in the U.S.
PLENARY PRESENTATIONS Cardiometabolic Disorder and Diabetes Management in the U.S. Bryce Smith, PhD, MSSW Samuel Arce, MD, FAAFP Reducing Incidence and Complications of Diabetes: The Role of Evidence-based
More informationEnhancing the Health of Our Communities Alisahah Cole, MD & Chief Community Impact Officer. December 2018
Enhancing the Health of Our Communities Alisahah Cole, MD & Chief Community Impact Officer December 2018 Goals GET INFORMED GET INSPIRED GET UNCOMFORTABLE GET ACTIVATED Carolinas HealthCare System Is Our
More informationApproved Care Model for Project 3gi: Integration of Palliative Care into the PCMH Model
1 Approved Care Model for Project 3gi: Integration of Palliative Care into the PCMH Model OneCity Health Webinar January 13, 2016 Overview of presentation 2 Approach to care model development Project overview
More informationFax to Quit: A Model for Delivery of Tobacco Cessation Services to Wisconsin Residents
Fax to Quit: A Model for Delivery of Tobacco Cessation Services to Wisconsin Residents Robin J. Perry, BS, CHES; Paula A. Keller, MPH; Dave Fraser, MS; Michael C. Fiore, MD, MPH ABSTRACT Research has shown
More information