1. The Learning Collaboratives at PDI Leads Workshop Wave Hill March 25, 2014

2. UHP History Urban Health Plan, Inc. was founded in 1974 A network of federally qualified health centers comprised of nine clinical sites, nine school based practices, and three administrative and program sites. In 2014 UHP served more than 68,000 patients Close to 350,000 visits Awarded Level 3 recognition as a NCQA Physician Practice Connections—Patient-Centered Medical Home (PPC-PCMH) in 2009 and 2012 Joint Commission accredited since 2003

3. Background 2001: invited to join the HRSA Asthma II Learning Collaborative 2002: Became the asthma star team: initial registry size 2,000. Current registry: 11,000. 2003: Spread the Collaborative Model to clinical and non-clinical topics 2005: Created The Institute for the Advancement of Community Health (internal QI institute) 2015: QI models-UHP’s foundation for continuous improvement and transformation

4. QI Models Learning Model Chronic Care Model Model for Improvement

5. Enter the QI model slides

8. Repeated Use of the Cycle Hunches Theories Ideas Changes That Result in Improvement A P S D DATA A P S D A P S D A P S D

9. Community Resources Self- Mgmt Support Delivery System Design Clinical Information Systems Strategies for Each Component of the Care Model Overall Aim: Implement the Care Model A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A A P S D A P S D A P S D A P S D A P S D A P S D D S P A Leadership Decision Support D S P A

10. Three Performance Improvement Projects Asthma HIV Testing Diabetes

11. Asthma Project Participated in the HRSA Asthma II Learning Collaborative with Health Centers across the North East (2001) Applied the evidence based QI models Learned how to improve and track population health Received an Asthma Management Award from the Environmental Protection Agency (2009) Dissemination of Evidence Based Guidelines to all Providers Development of an Asthma Curriculum Asthma Action Plans provided to all patients with asthma Integrated Pest Management Referrals Repurposing of positions over time-we now have Health Educators at all sites

12. Asthma Results

17. Asthma Hospitalization Rate among Children (0-14)

18. HIV Testing Before 2010-UHP utilizes HIV counselors to provide HIV pre and post test counseling 2010-NYS requires all patients ages 13-64 to be offered an HIV test 2011-Funded by Gilead Sciences Inc. An internal multi site learning collaborative approach to transform how HIV testing is conducted at UHP 2011-Primary Care Providers and Medical Assistants conduct testing at all sites and Counselors are repurposed UHP develops a successful data driven strategy with practice coaching to drive improvement 2012-Funded by Gilead Sciences Inc. to lead five other CHCs to integrate HIV test offer

21. Diabetes 2013: UHP implements diabetes project Focus on one primary care provider’s panel of patients with uncontrolled diabetes (Hba1c >9) (N=122) Multi-disciplinary Team Based Approach Review of QI data monthly and action taken to improve key measures Team Case Conferences on patients with Hba1c =>12 Integration of right level of Care Management

23. Additional Results 98% of the Physician Champion’s patients with diabetes have a documented Hba1c within the past 12 months (N=500) 50% of patients who started with an HbA1c value of >9 now have an HbA1c <9 (based on last recorded value) (N=103)

24. Strategy for Establishing Successful Learning Collaboratives Ensure Senior Leadership commitment and resources UHP sets up learning collaborative structure with advisement from an Expert Panel Establish the Population of Focus and Goals for each project Select and engage the Team (weekly meetings) Train Team on QI models and evidence based guidelines Set up metrics and data reporting system and track measures

25. Strategy for Establishing Successful Learning Collaboratives (cont.) Engage in process mapping and re-mapping Track and share performance metrics Provide targeted practice coaching Share best practices through learning sessions Write and finalize protocols

26. Example of How to Set up a DSRIP Project as a Learning Collaborative UHP establishes the project structure in collaboration with Expert Panel to Plan Project details Select the population of focus per site (example: total of 8,000 asthmatics) Establish metrics, baseline, and reporting system Select the Team (all PPS providers that will participate in the project-ensure leadership commitment to participate) Train the Team on QI models and the Project itself

27. Example of How to Set up a DSRIP Project as a Learning Collaborative Team meets to conduct PDSA cycles Track and share performance metrics Engage Team in Learning Sessions and share best practices Write and Finalize Protocols Celebrate Success!

28. Life of a Learning Collaborative Testing Sustaining Spreading Sustaining Formalizing Transformation

29. Thoughts and Questions?