1. Health Federation of Philadelphia
CDC 1422 Grant: The Philly Difference, Connections for Better Chronic Care A Partnership with the Philadelphia Department of Public Health
Health Federation of Philadelphia
Funded 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 Health
Spectrum Health Services
3+ SITES
2 SITES

4. Esperanza Health Center
Family Practice & Counseling Network
Esperanza Health Center
3 SITES
3 SITES

5. Project Goals
Reduce 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 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

7. 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

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 programs
Provide 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 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

12. Initial Measure Set
Health Centers’ number/percentage of adult patients with a diagnosis of:
Diabetes patients
Levels of control – 39% a1c >9 or no a1c
Hypertension – 12,245 patients
Levels of control – 62.7% with BP <140/90
Smoking -
Cessation counseling

13. Pop IQ Trend Chart on Diabetes Control

14. Pop IQ Trend Chart on Hypertension Control

15. To run the report or check data definitions:

16. 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

17. 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……

18. Questions/Discussion