CommunityHealth Because No One Should Go Without Healthcare May 7 th , 2015: Board of Directors Meeting Strategic Plan Focus: Quality
Strategic Plan (2015-2017) Mission : Serving those without essential health care Vision : Delivering healthier communities The Largest Free Clinic in the U.S. ACCESS • Provide a medical home to those in need • Provide the optimal mix of primary and specialty care services • Grow our patient base through partnerships and community outreach SUSTAINABILITY • Develop/launch “Celebration of Health” event(s) • Grow and diversify revenue sources • Strengthen “sustainable” partnerships with focus on volunteer base, operational partners and funders VALUE QUALITY • Demonstrate progress toward achieving • Enhance service delivery to improve coordinated care and reducing service gaps health status • Quantify the value/contribution to reducing • Track and communicate clinical outcomes costs to the health care ecosystem • Demonstrate continued improvement in • Develop/enhance partnerships across patient satisfaction and engagement clinical, educational, and research missions Population Health 2
Oh, How Far We Have Come….. Quality has driven the implementation of increased services at CommunityHealth – ensuring our patients are receiving the care they deserve . Let’s take a little trip down memory lane…. 3
Pharmacy Operations 4
Dental Before…. Nothing! Patients were often referred to ED due to pain issues, or a referral partner; which many patient's did not follow through on due to cost. 5
EMR Conversion 6
Enhance Service Delivery to Improve Health Status “ Healthy citizens are the greatest asset any country can have.” ― Winston S. Churchill • Strategic Plan is the roadmap 1. Planning begins in August/September of each year for our Annual Implementation Plan (AIP) 2. SMART Goals and “Proof Points” are generated so that we are able to measure, track and “prove” our effectiveness 3. Program Committee involved in Quality Improvement project selection 7
Enhance Service Delivery to Improve Health Status • Lung Health Program • Spirometry • Pulmonology • Smoking cessation services Diabetes Care Group • • Enroll 50 patients in diabetes care group by end of 2015 • Women’s Health Program • Increase breast cancer screening rate • Increase cervical cancer screening rate • Pharmacy New medication counseling techniques through Picture Rx • • Medication Therapy Management (MTM) appointments • Oral Health • QI project for Decayed, Missing and Filled Teeth (DMFT) • Health Education • Demonstrated improvements in clinical outcomes, and behavior/self-efficacy measures related to self- management in diabetes education, nutrition education, and La Vida Sana • Social Services • Depression Screening using PHQ9 tool • Improved patient/provider communication at time of patient discharge 8
Enhance Service Delivery to Improve Health Status Continue to demonstrate our commitment to on-site clinical training and education opportunities by…… • Report QM measures for individual residents and residency and medical student clinics Conduct resident in-services on a variety of topics (DV, depression screening, lupus/Hep C • treatment) • Explore new partnership with College of Dental Medicine-Illinois (Midwestern) • Become a community site for Kennedy-King hygiene students • Maintain current student nursing partnerships with DePaul University, UIC, and Rush and explore addition of new partnership with Resurrection University • Maintaining our previously established partnerships for pharmacy student training programs with Chicago State University, Midwestern University, University of Illinois at Chicago, and Roosevelt University • Establish a curriculum for interprofessional education (based on disease state, i.e. HTN, DM, Hyperlipidemia) 9
Track and Communicate Clinical Outcomes 1st Quarter 2014 Avg 2015 2015 Goal Uninsured Medicaid HMO Diabetes Guidelines Pts w 2 A1c results 3 mos apart in past 12 mos 58% 56% 59% 46.6% NA Pts w A1c < 7% 30% 28% 31% 49.5% 34.0% Pts w A1c < 8% 50% 48% 51% NA 46.5% Pts w A1c < 9% 62% 61% 63% NA NA Microalbumin/Creatinine Ratio in past 12 months 62% 62% 64% NA 78.4% Pts w annual foot exam 37% 42% 38% 55.7% NA Pts w annual eye exam 22% 22% 23% 27.8% 53.2% Pts on a statin 82% 82% NA 82.0% Pts w BP < 140/90 61% 63% 63% NA 37.8% Pts w flu shot in past year 24% 29% Pts w pneumovax 50% 59% Preventative Screenings Breast CA screening in past 2 years (50-75) 48% 46% 50% 38.5% 51.9% Cervical CA screening in past 5 years (30-65), past 3 years 61.6% 64.5% (21-29) NA 72% (every 3 yrs screen) (every 3 yrs screen) Colorectal CA screening (50-75) 46% 50% 47% 21.0% NA HIV test completed 41% 48% Vaccines Pneumovax for 65+ 42% 48% 43% NA NA Shingles vax for 60+ 26% 34% 27% NA NA Tdap last 10 years 34% 43% 35% NA NA HPV for patients 26 and younger 10% 11% 11% NA NA 10
Track and Communicate Clinical Outcomes Targeted QI Projects 2015 Diabetes : 2015 1 st Qtr Avg Uninsured Medicaid National Avg Pts w A1c < 9% 61% Microalbumin/Creatinine Ratio in past yr 62% 78.4% Preventative Screenings: Breast CA screening in past 2 yrs (50-74) 46% 38.5% 51.9% Vaccines: HPV for patients 26 and younger 11% 36.9% For all: Breast Cancer Screening Interventions: EMR automated reminders Manual reminders in appt notes section in EMR (new) • • • Resident huddles/leader board (new) • Nurse breast exam and PAP smear reminders • Direct patient outreach calls (new) HPV Vaccination Interventions: Diabetes Interventions: • Direct patient outreach calls (new) • Diabetes Care Group – direct patient outreach • Reminder calls to complete series once started • Health Literacy Handouts on DM Complications • Incentive for completion? (new) 11
Track and Communicate Clinical Outcomes ER Diversion Data 50% 45% 40% 43% 35% 30% CH before intake 31% 25% 20% CH established pt 15% 20% 10% 13% 5% 0% 1+ ER visits 2+ ER visits 2012 census data CH before intake CH established pt 2+ ER visits 7.8% 20% 13% 1+ ER visits 18.8% 43% 31% 12
Demonstrate Continued Improvement in Patient Satisfaction and Engagement Areas covered on annual Patient Satisfaction Survey • Patient Demographics Service Access • • Care Satisfaction • Set of miscellaneous questions – Affordable Care Act Questions – Patient Donation Questions 2014 Survey Conclusions • We continue to be rated very high by our patients • Surprising results coming out of the smart phone question • A large majority of patients are open to a small “fee” 13
Demonstrate Continued Improvement in Patient Satisfaction and Engagement Vision : Delivering healthier communities Current Patient Engagement Opportunities • Patient Leadership Group • Paso a Paso • Health Ed Opportunities Future Opportunities Community Health Workers • • UIC “community” residents at CH • Home visits • Patient Advisory Board 14
Questions? Megan Doerr, Director of Clinic Operations mdoerr@communityhealth.org Emily Hendel, Director of Nursing Services ehendel@commmunityhealth.org
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