CDC 1422 Grant: The Philly Difference, Connections for Better Chronic Care A Partnership with the Philadelphia Department of Public Health   Health Federation of Philadelphia HFP Learning Collaborative Meeting 3 June 4, 2015

Intranet Site Demo www.healthfederation.org

Data Addendum to Data Sharing Agreement For participants in the 1422 Philly Difference Project HFP Collaborative June 4, 2015   In addition to conditions agreed to in the HCCN Data Sharing Agreement that governs the HFP Pop IQ data warehouse, health centers, staff, consultants, and PDPH representatives participating in this project agree to the following: Any data shared, whether verbally or on paper, at Collaborative meetings is assumed to be confidential and not to be shared outside of these meetings without explicit written permission from any health center(s) to whom the data belong. While data may be discussed within collaborative meetings at the site and health center level, all data reported to PDPH and other external parties by HFP will be at the system level, i.e. across all participating health centers in the HFP collaborative.

Data Definitions

Blood Pressure Control Health Center B Health Center D Health Center I

Undiagnosed Hypertension Health Center B Health Center D Health Center I

Diabetes Control Health Center B Health Center D Health Center I

Smoking Cessation Intervention Health Center B Health Center D Health Center I

HbA1c Screening - Medicare Health Center B Health Center D Health Center I

HbA1c screening – non-Medicare Health Center B Health Center D Health Center I

Feedback from Assessments

Self-Management Goals Questions about definition (v. Treatment Goals) and Buy-In How/if /for and by whom this should be done MA’s v. Providers v. RN’s/BHCs/Nutritionists For all patients? For high-risk patients? For smokers/obesity? Needs: Motivational interviewing training Template and workflow development (EMR specific) Training our patients that they have a voice

Team Based Care Stable provider/MA dyads: the exception not the rule. Multi-professional teams in all centers: Care coordinators/case managers Nurses MA’s Behavioral Health Nutritionists In some cases, extends to front desk, lab staff, scanners.  

Team Based Care Needs: Next Steps: Help with operationalizing dyads (schedules, preferences) Risk stratification Care coordination/management resources Providers as CEO’s of their team Clinical skills for MA’s Empanelment/the care team working the panel Next Steps: Overview training – 90 minutes, with CME’s, CNE’s Tailored follow-up Totally aligned with PCMH

Medication Adherence In most cases, providers do all of med rec Concerns about moving any of this to MA’s Other team members do med rec for certain conditions (e.g. nutritionists for diabetics) Not currently using SureScripts Med History Some pilots for more pharmacy involvement (FPCN, Spectrum) Needs: Assistance with SureScripts Med History workflow to make helpful and not overwhelming Support on cleaning up the med list (e.g. end dates for acute drugs)  

Pre-visit planning Most groups are doing some form of huddles Some inconsistency across sites/provider teams Need: Incorporate pre-diabetes and undiagnosed hypertension into pre-visit planning Clean up around clinical protocols for initial treatment of diabetes and/or hypertension (updates, dissemination, EMR support)

Community Resources Strong processes to refer patients internally and/or externally to: diet/nutrition advice smoking cessation exercise programs/gyms Housing, domestic violence, etc. No one tracks external community referrals Needs: Better updated resources for case/care managers on available, local social services

Community Health Workers All four centers have some access to CHWs Two programs are external (CHWs not HC employees), two are internal Sustainability is difficult for internal programs (grant based) Needs: Exchange of information about what works/best practices with CHWs Identify sustainable funding/reimbursement More incorporation of CHWs into care teams  

Next Steps Initiating Team Based Care training Motivational Interviewing training TA with EMR pieces: Surescripts med history Cleaning up med lists Workflow and documentation of goals Spectrum i2i implementation I2i dashboards on key measures at all sites Hypertension update from external expert Others….?