Presentation on theme: "Health Federation of Philadelphia"— Presentation transcript:
1 Health Federation of Philadelphia CDC 1422 Grant: The Philly Difference, Connections for Better Chronic Care A Partnership with the Philadelphia Department of Public HealthHealth Federation of PhiladelphiaFunded by the Centers for Disease Control and Prevention, through the Philadelphia Department of Public Health
2 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.
3 Year 1 Participating Health Centers Delaware Valley Community HealthSpectrum Health Services3+ SITES2 SITES
4 Esperanza Health Center Family Practice & Counseling NetworkEsperanza Health Center3 SITES3 SITES
5 Project GoalsReduce rates of death and disability due to diabetes, heart disease, and stroke across Philadelphia.
6 Strategies determined by CDC Increase EHR adoption & use of HIT to improve performanceIncrease institutionalization & monitoring of quality measuresIncrease engagement of non-physician team staff in hypertension managementIncrease self-measured blood pressure monitoring tied with clinical support
7 Strategies determined by CDC Implement systems to identify pre-diabetes & undiagnosed hypertensionIncrease engagement of CHWs to promote linkages between health systems and community resources for adults with high blood pressure, pre-diabetes or those at high riskIncrease engagement of community pharmacists in MTM for high blood pressureImplement systems and increase partnerships to facilitate bidirectional referral between community resources and health systems, including lifestyle change programs
8 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.
9 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.
10 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 programsProvide an incentive of $15,000 per organization annually to help compensate for staff time spent on this project
11 Roles & Responsibilities of Participating Health Centers Designate a clinical leader as the main point of contact/participant in learning collaborative activitiesAllow/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 IQCommunicate regularly with HFP project staff on challenges and successes of project implementation
12 Initial Measure SetHealth Centers’ number/percentage of adult patients with a diagnosis of:Diabetes patientsLevels of control – 39% a1c >9 or no a1cHypertension – 12,245 patientsLevels of control – 62.7% with BP <140/90Smoking -Cessation counseling
16 Next StepsOn-site assessment of health center practice regarding chronic disease management:Self-management goal setting and documentationTeam-based carePre-visit planningCommunity resourcesCommunity Health WorkersMedication adherence
17 Future Collaborative Meetings 4th Thursday every two months?:March 26th, 2015May 28th, 2015July 23rd, 2015September 24th, 2015(Conflict with HIV Care Network meetings)Or……