Salt Lake County Health Department
Give Them Choices – Working with Clinics to Improve Patient Care
The population of Salt Lake County (SLCo) was 1,128,814 in 2017, with 21% of the population identifying as non-white and 18% identifying as Hispanic/Latino. The 2017 median household income for the county was $66,723, but disparities exist with Hispanic/Latino households earning 66% ($46,635) of what non-Hispanic/Latino households earned ($70,218). As of 2017, 9% of families lived in poverty and 10.6% of the population had less than a high school diploma.
Since 2009, SLCo faced increases in prevalence and death rates related to chronic conditions, which places increased burdens on clinics and healthcare delivery. The Salt Lake Initiatives for Diabetes and Hypertension (SLIDH) targets geographic areas with the highest disparities, including the eight most at-risk zip codes, all located in Downtown Salt Lake City and Northwest SLCo.
With these socioeconomic and chronic disease realities, healthcare providers have the intense responsibility to assess, diagnose, and intervene with their patients, and then educate them on the latest evidence-based best practices with limited time. However, when providers team up with partners and have effective processes in place, they can improve the quality of care they provide their patients. The goal of this initiative was to help clinics and pharmacies better acclimate from fee-for-service to value-based-care by engaging community clinics and pharmacies, as a local health department, in continuous patient care quality improvement measurement that will help improve diagnosis and management outcomes related to diabetes and hypertension.
To reach this goal, our team created the Improved Patient Care Project (IPCP) checklist, designed with quality improvement activities geared towards community clinics or pharmacies that may lack ancillary support or funding to compete with clinics that operate under large healthcare systems. The three objectives of this checklist initiative were::
To increase the amount of clinics and pharmacies that consider our public health team as long-term community partners while maintaining the same budget
To improve accurate diagnosis, care, and management of hypertension and prediabetes in contracted agencies by identifying gaps in protocols and utilizing workflow processes
To improve clinic usage of health information technology
The SLIDH team used their expertise as Health Educators, Registered Nurses, and a Chronic Disease Evaluator to create the IPCP checklist resources, including promotion flyers and posters, blood pressure logs, data tracking programs, use of health information systems, staff and patient training guides and videos, templates for workflow processes, algorithms and policies along with specific toolkits for implementation of all IPCP activities. Our team allowed agencies to select activities tied to their own priorities. Agencies were given nine months to implement the projects, submit supporting documentation, and complete the baseline and outcome evaluations.
Thirteen agencies completed the IPCP application and turned in supporting documents for their checklist activities by August 2017. Million Hearts blood pressure standards were required for all IPCP hypertension activities. Agencies implemented blood pressure self-management policies for patients (through at-home blood pressure monitoring) and staff (through trainings and workflow policies) using these evidence-based standards. After implementation of IPCP hypertension projects, 52% of patients improved their blood pressure control rate. Three agencies changed their approach to prediabetes, including newly diagnosing patients and referring significant numbers of patients to Diabetes Prevention Program (DPP). Agencies improved their utilization of Health Information Technology (HIT) through the use of alerts and reports for A1c, glucose, and high blood pressure. These changes affected current and future patients because of systemic changes implemented within the agencies themselves, including two low-cost clinics that obtained an EHR in response to the work they were doing with the checklist.
The program's success was tied to the IPCP checklist being designed specifically to align with agencies' pressing issues and desired accomplishments with simple, step by step activities that promote continuous, sustainable, upward progression of improvement activities that can be completed based on their readiness and timeline. Each agency filled out baseline evaluations before they started implementing projects and outcome evaluations once they completed their projects, which helped them realize the importance of the work they were doing. Also, the in-person assistance we received from our state's Quality Improvement Organization (Health Insight) helped our team efficiently provide support when meeting with healthcare delivery agencies.
Overall, eight clinics improved their electronic health records appropriate for treating high blood pressure and encouraged a multidisciplinary team approach to blood pressure control. Ten agencies completed projects that improved policies to facilitate identification of patients with undiagnosed hypertension and prediabetes and implement community referral systems for the DPP.
Since 2009, Salt Lake County (SLCo) faced increases in prevalence and death rates related to chronic conditions, which places increased burdens on clinics and healthcare delivery. The age-adjusted death rate per 100,000 people due to heart disease increased from 138 deaths in 2009 to 149 deaths in 2014. The age-adjusted death rate per 100,000 people due to diabetes increased from 23 deaths in 2009 to 28 in 2014. Countywide, 60% of residents are overweight or obese, with higher prevalences among residents self-identifying as non-white/Asian (69%-82%). Hypertension and diabetes affects 25% and 8% of the population, respectively.
Although providers are experts in their field, they are often expected to solve complex issues within one short patient visit of less than 20 minutes. Based on decisions made in the early 1990s, these short patient visits coincide with changes over time, including often-complex electronic health records, changing treatments and rules, increasing chronic disease burdens, and a growing number of patients with multiple chronic diseases and prescription medications. Despite the length of a patient visit not changing much over time, the amount of time physicians are actually talking to or examining patient averages eight minutes, with the rest of the time spent doing paperwork (Sinsky et al, 2016). Despite this limited time frame, primary care doctors are responsible for early detection and management of expensive chronic conditions including prediabetes, type 2 diabetes, obesity, and hypertension to help prevent increased risks of other serious health issues including heart attack, cancer, or stroke.This can be increasingly challenging when patients are advised to receive lifestyle counseling due to their chronic disease diagnoses. Historically, primary care physicians were primarily treatment-focused within fee-for-service models. Providers relied on medical interventions and continue to not have enough time or resources to focus on prevention, lifestyle modification, and chronic disease classes and education. For patients more at risk of chronic conditions, the need for a combined medical and preventive intervention approach is needed now more than ever.
SLCoHD has significant geographic disparities related to socioeconomic status and chronic disease burden as well. Communities with the most need often have less access to insurance and limited access to clinical care in their area. Salt Lake Initiatives for Diabetes and Hypertension (SLIDH) targets 293,000 residents in geographic areas with the highest disparities, including the eight most at-risk zip codes according to the 2017 Nielson SocioNeeds Index, all located in Downtown Salt Lake City and Northwest SLCo. These geographic areas, representing 293,000 people, had 30% lower median household incomes and were 78% more likely to not have health insurance coverage when compared to county averages. They had 29% higher diabetes prevalences, were 7% more likely to die from heart disease, and were 13% more likely to be obese. Life expectancy at birth was significantly less in our priority geographic areas, with areas like the Downtown Salt Lake region (73.1 years old) living 11 years less than residents living one mile away in the Salt Lake City Foothill region (84.7 year old). However, working within these geographic confines were challenging when few clinics were in these geographic areas and it was difficult to garner information from agencies regarding where their patients come from. However, all agencies were asked to identify their most at-risk patients and prioritize their efforts toward reaching these populations.
For this project, we reached nine clinics with 77,261 patients and four pharmacies with an estimated 11,000 patients. We were unable to only target participants within our geographic areas due to the complex relationship between patients and their access to clinics, but a majority of the agencies we worked with were either low-cost/free clinics or were located in our priority geographic locations.
The relationship between public health and clinical care changed after the Patient Protection and Affordable Care Act became law, which both increased funding for public health programs nationwide and further pushed value-based care models into mainstream billing and spending mechanisms. Historically, our program worked on built environment changes in communities and schools, often not working directly with primary care clinics. There was no bridge connecting public health and primary care providers focused on diabetes prevention or hypertension control. Few other programs within our health department had worked with blood pressure control, diabetes prevention, and clinical partners.
With new funds to prioritize public health work in clinical settings, our team started reaching out to primary care clinics and pharmacies to assess how we could forge partnerships. From 2015 to 2016, our team attempted to reach clinics through assessments and cold calls since we had no formal and up-to-date contact list. In 2015, our team conducted the Practice Assessment for Chronic Disease Management (PACDM), receiving 26 small to mid-sized clinic responses, most of whom were independent and focused on low-income patients. The assessment included questions about readiness for quality improvement, chronic disease prevention infrastructure, and health information technology. After receiving assessments, 19 clinics participated in in-depth interviews about their work, meant to be a catalyst for future projects. After the assessments were completed, our SLIDH team sent out RFAs seeking agencies willing to begin new Diabetes Prevention Programs (worth up to $25,000) and hypertension projects (worth up to $15,000) with our technical assistance. Despite some clinic and pharmacy interest in the significant financial assistance, our team could only fund a few agencies. The agencies selected were expected to create entirely new programs/classes for patients and clients. With these expectations, many agencies did not have the time or resources to fulfill the 1-2 year commitment of the funding opportunity. The narrow reach of activities, reaching only a fraction of the patient population that could fit into classes and pilot programs, made for expensive and narrow outcomes. While four agencies completed the diabetes prevention and hypertension management grants, there were limited sustainable mechanisms for the programs to continue after financial assistance was depleted. Furthermore, there were no referral or diagnosis policies and procedures within the clinics and pharmacies to help with program retention.
Our previous attempts to work directly with clinics led to four agency partnerships in two years, whereas our IPCP checklist led to 13 partnerships in half the time (1 year).
First, our approach was easier for agencies to accomplish - In past health care work, agencies were less likely to adequately complete activities due to various time constraints, staff turnover, and issues with agency readiness. Instead of one large project, of which an agency was responsible for creating a program from scratch, agencies were given 49 different activities, which built upon one another, with small financial incentives for each. They had the choice of which work they were capable of completing, ranging from participating in webinars or joining coalitions to starting a long-term at-home blood pressure monitoring program, or a referral system to the Diabetes Prevention Program (DPP). For example, clinics that saw a prediabetes problem in their clinic were more willing to start projects that systematically identified prediabetics, created a DPP class in their agency, or established a referral system to a DPP class outside their agency, despite only receiving $400-$1000 for these activities. Our team's financial incentive and technical assistance were often enough to get agencies to begin work they were already interested in doing but were previously delayed.
Second, our approach was cheaper - Each of the 49 projects were worth between $100 and $1,000 with a maximum of $5000 per agency. The checklist provided small incentives for manageable activities, which allowed our program to distribute incentives and resources to more agencies for less money. The checklist took the place of all hypertension activities, which allowed our program to continue providing start-up funds for new DPP classes in other settings such as non-profit community organizations who do not already have existing healthcare infrastructure but have large reaches to at-risk communities.
Third, our approach allowed for faster results, and more partnerships - The thirteen agencies completed 166 activities over a 9 month time frame. The average incentive for an activity was $327. Most of the activities were policy and procedure changes, or new awareness of disease prevalences, which impacts all patients over time. The activities required frequent meetings and technical assistance from our team, which helped build quick relationships. While each agency had their own level of skepticism and distrust for funding agencies, the fact that our team allowed agencies to pick from a list of realistic and interesting activities helped them open the door to a long-term relationship with our team. To help in these partnerships, each clinic had a person from our team as their point-of-contact throughout the process, but were referred to other partners or staff depending on the help they needed. Healthcare agencies want to improve their workflow, help patients effectively manage their chronic conditions, and better understand and track their patients' health at an agency level, and once they realized our team was there to facilitate that work both financially and personally, they were more responsive.
The SLIDH team recognized that quality improvement organizations and other state and local health departments had conducted projects on practice facilitation and quality improvement that followed the similar strategies and approaches to complete projects with clinical-based agencies. While not new to the field of public health, the team's IPCP checklist was unique in several ways:
An all-in-one approach to our grant-required activities - Our team's funding is based entirely on a grant from the CDC. Each of the 49 activity options in the checklist apply to specific grant activities our team is responsible for when working with clinics and pharmacies. Instead of focusing on each activity with each clinic at different times, the checklist allows for a team member to work with certain clinics to do all activities selected. This helped streamline grant work at the local health department level.
Clinical agencies had freedom to select what was important to them - The checklist gave already-burdened agencies an opportunity select their own activities based on their own relevant needs and patient population. The activities ranged from hypertension management, undiagnosed hypertension, care coordination with external health professionals, diabetes prevention, and healthy living activities such as food drives and Physical Activity as a Vital Sign. Concerns such as time restraints and staff turnaround are less relevant because they can pick and choose what â€˜they â€˜ can manage and because these project put sustainable procedures in place regardless of staffing. The projects as also weighed differently depending on the level of difficulty and extent of project complexity which enabled the practice to prioritize and reimbursement aligned with time taken to accomplish the project's goals.
Accomodating to a variety of partners - The checklist was developed with the involvement of clinic and pharmacy partners, troubleshooting and brainstorming techniques, feedback from existing partners, and idea sharing with surrounding local health departments and the state health department. The checklist provided various options for different types of healthcare agencies, regardless of size or location. Those that completed the checklist were from a wide range of agency types, including free community clinics with no EHRs, low-cost clinics transitioning to EHRs, clinics with over 50,000 patients per year, community pharmacies, and returning clinic partners continuing on with larger projects.
IPCP activities helped justify future funds and activities - Each partner that worked on IPCP checklist activities were provided technical assistance in establishing baseline and outcome data tailored towards their checklist choices and level of experience, which helped exemplify the work they did. One clinic used the work they did on the activities to justify funding for a new EHR and for new community health workers, helping sustain the impacts of the completed activities. The checklist also led to other innovative and creative projects within clinical settings. For example, an agency that started referring prediabetes patients to DPP saw value in referring DPP participants to home-health community health workers. Others now take blood pressure at dental screenings and then refer to hypertension management education in clinics.
SLCoHD provided clinics and pharmacies with professional facilitators within the SLIDH team that have the experience to provide evidenced-based resources and the time to help improve healthcare providers' patient care. They facilitated quality improvement activities in a timely and organized fashion with little interruption to the daily practices of clinics. Our team created the IPCP checklist to address gaps in the healthcare system and was designed to support the providers and tie work to their specific needs related to chronic disease management. The SLIDH team received feedback after implementing prior RFA projects was that the projects, including concerns about how cumbersome and overwhelming the RFA process was, how much time it took, and that clinic and pharmacy staff were not experienced enough and were ill-equipped to complete the RFAs and broad projects. Clinics indicated that they needed specific clinical quality improvement opportunities and policies relating to hypertension accuracy, undiagnosed hypertension, hypertension measurement, blood pressure self-management, diabetes prevention education, prediabetes screening and diagnosis, referrals to National Diabetes Prevention Program and/or becoming a recognized DPP site. Agencies also lacked evidence-based patient educational training materials and toolkits. The SLIDH team determined that providers and their staff could benefit from the health department's technical assistance in a new and innovative way that differed from past attempts at quality improvement.
To achieve the goals and objectives for the IPCP checklist, agencies needed to know their population. Specific activities aimed to help agencies collect aggregated data related to their patients with hypertension and prediabetes. Clinics and pharmacies tracked patients' blood pressure, A1c and blood glucose through their EHRs or charts, which often included a patient's baseline and outcome information. If improvement was shown, then an end goal was to implement a finalized office policy or procedure reinforcing the practice improvement. SLIDH facilitators worked to overcome any barriers providers encountered including creating additional tools upon request.
The IPCP checklist provided agencies the opportunity to address various topics involving workflow and patient care management. In the Care Coordination section, several activities aimed to improve collaboration efforts between healthcare teams, including pharmacies and Community Health Workers (CHWs) by encouraging team-based care approaches to help address gaps in patient care and education. The SLIDH team provided assistance with bidirectional community referrals and/or community resource informational handouts. SLIDH hosted CHW trainings where they invited potential candidates for an initial training, then encouraged CHW's to become DPP lifestyle coaches. IPCP activities provided clinics and pharmacies resources and encouraged use of CHW's within their patient care regimen. SLIDH hosted Collaboration Action Meetings where they invited clinics and pharmacies to gather together to discuss shared approaches to improve communication and effective collaboration, then worked toward sustainable collaborative practice agreements.Three Collaborative Practice Agreements were completed, signed and implemented into pharmacies practice since introducing IPCP activities to clinics and pharmacies.
Another section focused on healthy living activities that reinforced lifestyle behaviors that have been shown to reduce the risks of hypertension and diabetes. Clinical staff and providers worked on healthy living activities by assessing where patients lived and what types of wellness materials they wanted. They then provided nutrition and physical activity resources that were nearest to patients homes and most useful to their patients. Clinics and pharmacies also provided patients with resources about community health programs like low-cost nutrition and physical activity resources, assisted in food donations and community outreach projects, and disseminated healthy lifestyle materials. The SLIDH team provided information and training to three clinics and one pharmacy on health department support programs including Asthma Home Visitation Program, Tobacco Cessation, and Obesity Prevention. Activities completed within this category included Physical Activity as a Vital Sign, prescription for physical activity (Green Rx), Fruit and Vegetable prescription (FVRx), family meal planning, and healthy food access.
The Diabetes section was focused on preventing type 2 diabetes (T2D) or prediabetes among patients. Screen Test Act Today (STAT), a toolkit and guide created by the CDC and American Medical Association (AMA) for healthcare providers, provided agencies with new tools to help patients delay or prevent the onset of T2D and refer patients with prediabetes to the National Diabetes Prevention Program (DPP). National DPP is an evidence-based, culturally sensitive year-long diabetes prevention community health program created by the CDC to help those at risk for T2D eat healthier, increase their physical activity, lose weight, and gain long-term knowledge and skills to sustain lifestyle change. Clinical trials of the NDPP program have shown that participating in National DPP can delay or prevent the onset of T2D with 5-7% weight loss and 150 minutes of physical activity per week by 58% (or 71% for those 65 years or older). The IPCP checklist broke down the STAT toolkit guidelines into smaller achievable activity steps for clinics and pharmacies to accomplish. Those steps included activities such as prediabetes awareness to patients, prediabetes screening, prediabetes testing, identifying prediabetic patients during a point-of-care visit, identifying prediabetic patients retrospectively by generating a registry from health records, utilizing electronic health record prediabetes alerts, developing a referral workflow process or policy into the National DPP, and becoming a site for the National DPP. SLIDH added other prediabetes activities to the IPCP checklist that further supported the STAT guidelines such as prediabetes staff trainings and education. There were a total of 11 prediabetes IPCP checklist activities. Clinics and pharmacies chose the number of prediabetes checklist activities to accomplish according to their interests, capacity, and time. This flexibility allowed each organization to reach their prediabetes milestones according to their own abilities, resources, and timetables. It also allowed organizations to build off of the work they completed the previous year in preventing type 2 diabetes- improving year to year.
One pharmacy was able to collaborate with a local community clinic to provide National DPP services to their patients and community members in the low-income population area of West Valley of Salt Lake City, Utah. The community clinic's health care providers referred patients to the pharmacy DPP class. Together the pharmacy and community clinic were able to achieve their objectives of increasing identification of prediabetic patients and refer them to useful community resources. Since 2016, five clinics and one pharmacy have become sites for the National DPP for their patients and community members, meaning they hold the year-long prediabetes classes according to CDC requirements. Four out of these six organizations have held NDPP classes in Spanish for their patients as well. Objectives were met because nearly every DPP participant reported behavioral improvements to their physical activity level, food awareness, overall health, and most lost weight.
The most commonly utilized sections in the IPCP checklist were focused on hypertension management and undiagnosed hypertension. Clinics were encouraged to use health information technology fully by pulling several NQF reports, specifically NQF 59, on a regular basis to track control rates and other health data about their patients. Activities walked clinics through a follow-up process in response to the findings of these reports and working with contacting patients for any needed care. Some activities on the IPCP checklist were focused on blood pressure self-measurement training to help staff teach patients basic disease education, blood pressure self-monitoring and tracking, along with healthy lifestyle tips. Staff was trained on proper technique for teaching patients how they should monitor their blood pressure at home. Clinics and pharmacies developed and implemented policies for new hires and annual staff trainings about blood pressure measurement, management, and patient education. Pharmacies were able to implement the evidence-based strategy of tracking patient care over time to improve blood pressure control among their patients. One pharmacy increased monitoring of blood pressure quality data measures such as the number of patients that utilized the free blood pressure checks, tracking the number of high blood pressure readings, and number of referrals for follow-up to a physician.
Other activities in these hypertension-related section focused on implementing at-home blood pressure monitoring for patients, since many patients experience â€˜white coat' hypertension. Often, patients can't afford at-home blood pressure monitoring nor have the time to go to facilities with monitors frequently enough. One activity involved agencies implementing a home blood pressure machine â€˜Lending Library' to help with proper diagnosis of hypertension and decrease white-coat hypertension diagnosis for patients to check out. The at-home blood pressure monitor lending library provided patients access to validated blood pressure machines. Patients were empowered to take control of the process in improving their hypertension, learned accurate blood pressure measurement technique, and were taught proper blood pressure at-home tracking with the help of staff clinical support. These blood pressure lifestyle behavior change teachings were reinforced during ongoing clinic and pharmacy visits. Clinical staff also shared patient education materials from the American Heart Association to those identified with having elevated blood pressure and patients were given the opportunity to ask staff blood pressure questions. The SLCoHD created trainings and provided toolkits for clinical staff to begin this project.
Along with blood pressure monitor libraries, clinics and pharmacies were also able to implement and advertise free blood pressure checks to patients and community members. Providers were able to participate in a variety of opportunities including extending office hours, making appointments available for walk-in vital sign assessments, creating lists of validated kiosks, networking with their community to find alternatives for patients to meet specific needs (lack of funds or transportation for example), collaboration with neighboring pharmacies to help measure and provide patient support, and the lending machine programs. These free blood pressure checks allowed clinics and pharmacies to increase identification of patients with undiagnosed hypertension.
Lastly, there was a team-based care section on the checklist that helped connect and engage community partners whose patient care goals align. The IPCP activities worked to facilitate the establishment of effective communication and establish plan of care protocols, with an end goal of implementing Collaborative Practice Agreements (CPA). Activities were focused on referral to the National Diabetes Prevention program, medication adherence, hypertension management programs, nutrition and physical activity, healthy living education, tobacco cessation, referrals to evidence-based classes and patient care specific to their needs. These activities have helped connect partners with other health department programs as well as provided an avenue for increased and effective communication between clinics and pharmacies.
SLCoHD connected pharmacies and community clinics to establish CPAs by way of IPCP and Collaboration Action Meetings. Through the IPCP activities, one community pharmacy joined their individual cities Healthy Communities coalition as a medical expert. This coalition helps local leaders, community businesses and citizens understand and prioritize their population's health concerns. This information helps partners to take what they have learned and to personalize their patient care by addressing pressing community health concerns. For example, if many members of a community are concerned that there are not enough safe sidewalks and poor access to parks and trails, they may not feel safe while walking or exercising. The provider can work to find alternative low-cost or free resources in their community, as well as work with community leaders to help improve their community, such as advocating for better access to trails, improved signage and providing continuous sidewalks. One community pharmacy joined and participated in the statewide Team-Based Care Coalition.
SLIDH facilitators built strong trusting relationships with each clinic and pharmacy. SLIDH provided any necessary technical assistance, templates, and resources to achieve completion of activities. Each clinic had a champion that spearheaded their IPCP projects to completion. The strong relationships have led to continued collaboration that extends beyond the 1422 grant. In designing the checklist, SLCoHD used all evidence-based criteria and practices referencing the Million Hearts, American Heart Association, and Joint National Commission 8 Hypertension practice guidelines, National Diabetes Prevention Program practice guidelines and CDC 1422 grant activity requirements.
Salt Lake County policy requires that every grant or funding opportunity be open to every eligible agency within Salt Lake County. Therefore, applications went to all primary care, internal medicine, and community clinics and pharmacies and federally qualified health centers. The checklist items were tied to financial incentives and were promoted through our SLCoHD webpage and community health listserv. Applications were required to be accepted on a first come, first serve basis. SLIDH team members personally reached out to clinics and pharmacies that work with low income and disparate populations in our grant's priority areas to encourage them to apply for the opportunity. The 2017 IPCP checklist time frame was from November 1, 2016 to August 25, 2017.
In 2014, the Utah Department of Health and SLCoHD were awarded a grant from the CDC to work with community clinics and pharmacies on hypertension control and diabetes prevention.This grant funding provided incentives for providers to implement sustainable improved processes and/or policies. SLIDH had $40,000 available to healthcare providers and $30,000 available to community pharmacies. IPCP checklist included financial incentives for all 49 activities, ranging from $100 to $1,000 with a maximum allotment of $5,000 per clinic or pharmacy.
Several stakeholders were involved in this process, including the Utah Department of Health EPICC program staff members who helped to guide the SLIDH team on grant guidelines. HealthInsight, Utah's QIN/QIO, helped to build relationships with clinical partners and guided the SLIDH team on understanding processes, workflow, and policies within the clinical setting, including EHR's, required quality reporting, ACOs, and other mandates put in place through the Affordable Care Act..
To foster collaboration with community stakeholders, the SLIDH team assigned a lead facilitator to each applicant to provide technical assistance and support. The lead facilitator supported their clinics and pharmacies by communicating on a regular basis via email, in-person and conference calls, tracking progress of IPCP activities, creating and providing toolkits and resources. The facilitators also coordinated training opportunities with other community partners and county programs, including resources like asthma home visitation programs, chronic disease classes, healthy food access, opioid overuse and medication drop box campaigns, tobacco cessation programs and use of Community Health Workers.
Through IPCP, clinics and pharmacies became more engaged in community outreach. One local pharmacy participated in a healthy food drive, another local pharmacy participated in A1C and blood pressure screening events/health fairs that helped establish relationships between stakeholders and other healthcare entities. A local clinic joined the Utah Department of Health's Team Based Care Pharmacy Action Team. Although the team had been made up of only pharmacists in the past, having a clinic join provided a new perspective to a group, and provided key input and suggestions that helped progression of their action items.
To help clinics and pharmacies better acclimate from fee-for-service to value-based-care through continuous patient care quality improvement measurement related to prediabetes and hypertension, the Healthy Living team incorporated the Improved Patient Care Project checklist. The objectives of this checklist were:
Objective #1: To increase the amount of clinics and pharmacies that consider our public health
team as long-term community partners, while maintaining the same budget
Objective #2: To improve accurate diagnosis, care, and management of hypertension and
prediabetes in contracted agencies by identifying gaps in protocols and utilizing
Objective #3: To improve clinic usage of health information technology
Overall, our team found that providing a menu of services with small amounts of funding attached was effective in drawing in more applications for the same budget and increased quality and completion of activities, meeting objective #1. In previous years, our team had separate contracts for each type of project and type of agency. In 2015/2016 Healthy Living contracted with three pharmacies to work on patient hypertension management, originally totalling $29,000 and impacting an expected 800 patients. However, one agency was unable to complete the work so they only received partial funds and limited reach. Overall, the Healthy Living team spent $22,737 for three projects that reached a total of 378 patients, equating to a cost of $60 per patient for the county with no sustainable mechanisms in place to change agency processes long-term. We also contracted with three clinics in 2016 to work on hypertension management with their patients. While one agency created a new sustainable policy rechecking blood pressure of patients receiving high BP numbers, the other two agencies provided short term services until funding ran out. Overall, the three clinics were given $28,875 and reached 530 patients, or $54 per patient, during the project period. The Healthy Living team also provided up to $25,000 to each agency willing to begin a Diabetes Prevention Program targeting priority population geographic areas or participants. As of December 2017, we have paid out nearly $125,000 for 6 agencies to create their own program, with a reach of 171 participants over 2+ years, equating to a county cost of $741 per participant.
In all, before the IPCP checklist and the focus on sustainable policy and workflow changes within agencies, the Healthy Living Program spent $176,012 over 2.5 years incentivizing eight unique agencies to create new hypertension and prediabetes programs, reaching 1,079 Salt Lake County residents. After switching to our IPCP checklists for clinics and pharmacies at the end of 2016, our program spent $50,700 in 1 year incentivizing 14 agencies to establish sustainable policies and programs for hypertension management and prediabetes, reaching a clinic population of 77,261 and an estimated pharmacy population of 11,000. Furthermore, our program is in the process of starting new IPCP projects with 5 clinics and 5 pharmacies in early 2018 while also reducing the funding to a maximum of $3,000 per agency. Not included in these numbers are the 4 agencies our team worked with through IPCP checklists that are doing further quality improvement work with us without funding. After agencies recognized the value of the changes they selected from the IPCP checklists, several pharmacies are now initiating collaborative practice agreements with clinics, and clinics are establishing referral systems with other agencies, all without financial incentives.
Objective 2 was mostly met, despite challenges with data collection. Overall, all agencies working on IPCP checklist activities completed most or all of their work. In participating agencies, 52% of patients improved their hypertension numbers through blood pressure monitor lending programs and other hypertension projects after implementation. Three agencies changed their approach to prediabetes, including newly diagnosing patients and referring significant numbers of patients to DPP. Severn agencies changed their hypertension measurement and diagnosis policies to meet Million Hearts standards. However, several agencies were unable to complete the evaluation data requested of them, with half of the agencies not completing baseline data and one not completing outcome data. This was due to various factors, including the complexity of the questions in the evaluations, data restrictions due to differences in each agency's electronic records, and staff turnover in agencies. However, agencies completed the activities, despite data issues, and provided evidence of each of their completed activities.
Objective 3 was met, with agencies improving their utilization of HIT through the use of alerts and reports for A1c, glucose, and high blood pressure, and new access to information for patients through patient portals and after-visit summaries. These changes affected current and future patients because of systemic changes implemented within the agencies themselves, including two low-cost clinics that obtained EHRs in response to the work they were doing with the checklist. Unfortunately, a lot of the changes to agencies' information technology improvements took longer than expected, so much of the impact was not measured because agencies were still working through technological issues and staff training. However, follow-up work will be conducted in 2018.
The Healthy Living team's evaluator conducted baseline and outcome evaluations for specific quality improvement activities agencies worked on to help determine the actual real-time impact patients were experiencing because of the changes agencies were making. This primary source data came directly from the agencies working on IPCP checklist activities, with baseline data coming from before implementation of projects and outcome evaluations coming from after implementation. The evaluator first provided each agency a readiness survey through Survey Monkey to determine the size, needs, and opportunities moving forward. After the survey and after agencies finalized their IPCP activity selections, the health educator assigned to each agency brought baseline evaluations specific to the type of activities each agency was interested in. Lastly, a month before the projects had to be completed, our team sent out outcome evaluations. The evaluator used descriptive statistical methods to determine the impact of the various activities on agencies' patient populations.
To help make sure the IPCP checklist process was effective, the team had each agency submit specific evidence for each activity they selected. Examples of evidence included copies of EHR quality reports, copies of class schedules for new DPP classes, samples of after-visit summaries, and copies of new policies and procedures implemented. Agencies completed and sent verification for 96% (124 out of 129) of their activities.
Based on the success of the checklist in the first year, the team adjusted the amount of money for each of the activities, and even eliminated old and added new activities, based the amount of time to took to complete and the amount of resources it took to implement activities. Our team also reduced the amount of funding allotted per agency, but this was more due to budgetary constraints in our program and not based on the ability of agencies to complete the activities selected. Agencies did experience barriers when attempting to complete the 2-3 page baseline evaluations. While many of the questions were based on already existing quality measure questions they have to report to federal agencies, they remained confusing and often unanswerable in the timeframe available. Furthermore, some smaller agencies had no quality improvement or data manager, leaving medical assistants or physicians themselves to answer the evaluation questions. Some agencies were already overwhelmed with systemic changes to health insurance, staff turnover, and care, which limited the amount of time they could take to actually collect the specific data in accurate ways. Frequently, our team allowed agencies to make estimates for their patient populations and the amount of patients with certain conditions because they often didn't know how to retrieve or input such information. Many of the IPCP checklist activities were meant to help agencies collect such information for the first time, making baseline data hard to collect if they hadn't learned how to do it before. In response, the outcome evaluations were simplified, with agencies reporting that it was easier to fill out and made more sense. Unfortunately, this made it more difficult to compare baseline and outcome evaluations.
In relation to the overall checklist implementation process, the first lesson learned was that patient continuity of care relies heavily on provider collaboration and communication. Clinics and pharmacies often work in separate locations, using health information technology (HIT) that are not compatible and have no guidelines regarding education, so they rarely know what the other providers are teaching the patient. These gaps in communication led to a fear of inconsistent teaching and lack of patient education reinforcement. The IPCP checklist helped bridge the gap between providers and ancillary team members by formulating consistent work plans, processes and consistent materials that all healthcare providers began to implement. The team intentionally broke the checklist down into small manageable activities that built upon each other in order to reach objectives. The checklist had activities, such as collaborative practice agreements (CPAs), that helped ensure that patient care activities were aligned with agencies' specific care plan goals, therefore guaranteeing consistent, reliable communication and education for all clinicians involved with patients.
Secondly, agencies were receptive to funds that were supplemental. Giving them the opportunity to select their own activities with only small financial incentives, they were not dependent on the money they received and instead treated it as supplemental to their existing funds. Seeing as nearly all activities were completed, the funds were simply a nudge to help complete work they were already interested in.
Lastly, evaluating agencies' activities were challenging, partly due to the limited amount of funds we provided to them and because it took an unexpectedly longer amount of time than originally expected for agencies to gather the data necessary. In response to these issues, the SLIDH evaluator simplified future evaluations and made broke down more complex questions into smaller and simpler parts so that it wouldn't be overwhelming.
In relation to partner collaboration, the SLIDH team learned that if clinical care teams (i.e. physicians, medical assistants, nurses, etc.) and ancillary team members (ie. pharmacies and Community Health Workers) built rapport with one another, it led to a recognition that their goals were aligned, making it easier to agree on effective communication modes, and ultimately create an established trusting relationship for future patient care. When such a relationship was built, they relied on one another for referrals, feedback and follow up care, and began to advocate for one another. For example, one clinic's physician was initially hesitant and skeptical about working with other providers and pharmacies because he believed both professions had separate roles and goals. After working on the IPCP checklist with a pharmacy, he realized the benefit to both his patients and his practice. The collaboration actually saved the provider time by having the pharmacist conduct the medication therapy management and assist patients by teaching them blood pressure self management, medication adherence and lifestyle coaching. Unexpectedly, after conducting medication therapy management to the physician's patients, the pharmacy communicated to the SLIDH team that stress was one of the biggest patient complaints. In response, SLIDH created a â€˜Key to Managing Stress' handout that the pharmacy and clinic used simultaneously to counsel patients, reinforcing the IPCP checklist goal of continuity of care between clinical partners.
Also, Utah's Quality Improvement Organization (Health Insight) was crucial in reaching clinical agencies and being a resource for clinical questions. our team found that working with Health Insight allowed easier access to clinical agencies when reaching out and were a significant resource when agencies had questions about specific electronic health record or workflow issues. Their existing relationships with clinics and pharmacies helped save our team time and provided an extra layer of legitimacy and trust.
For the checklist to work effectively with diverse clinical agencies, the SLIDH facilitators had to be receptive to criticism and suggestions for improvement. SLIDH took special care to assess each clinic individually to obtain details on current practices, and were open to suggestions on how the practice wanted to make improvements. The impact of such open communication can be seen through the the creation of our stress management motivational interview tool discussed above and the frequent adaptation of tools to each agency's own populations and needs. For example, the SLIDH team redesigned the blood pressure tracker log to be more patient friendly by making a simple to use version that included instructions for accurate measurement, hypertension guidelines, resources, a blood pressure goal, and a heart rate log. Some agencies preferred their patients to have a hypertension self-management tool that was more more visual, so the SLIDH team adapted the tool so that when turned sideways it could be used as a graph for providers and patients. Furthermore, with the our team's continued communication and collaboration, we were able to utilize a IPCP checklist pharmacy partner to translate materials into Arabic.
The IPCP checklist included several activity options related to other health department programs that often go unnoticed. Some of these activities included opioid awareness, medication drop boxes, asthma home visitation, tobacco cessation programs, the Diabetes Prevention Program, and obesity awareness. Upon learning of the SLCoHD Asthma home visitation program, one pharmacy immediately referred two patients the same day knowing that this family had been having multiple issues and he assessed that some of the problem may have been environmental as well as a need for additional education and support. Many of the other programs in our health department shared grant requirements related to working with clinical agencies to help improve patient outcomes. After the checklist, two pharmacies created a Healthcare Provider Tobacco Quitline Referral policy for their patients and three clinical agencies implemented procedures for training new staff members on proper use and referral to the Tobacco Quit Line.
While a cost/benefit analysis was not done, it was clear that the checklist reached more agencies and patients despite a smaller budget for fiscal year 2017. Before the IPCP checklist, the Healthy Living Program spent $176,012 over 2.5 years incentivizing eight unique agencies to create new hypertension and prediabetes programs, reaching 1,079 Salt Lake County residents. After switching to our IPCP checklists for clinics and pharmacies at the end of 2016, our program spent $50,700 in 1 year incentivizing 14 agencies to establish sustainable policies and programs for hypertension management and prediabetes, reaching a clinic population of 77,261 and an estimated pharmacy population of 11,000.
With the support of Health Insight, the Utah Department of Health, and previous agencies that went through the checklist process, the IPCP checklist has a substantial amount of commitment from stakeholders. Some stakeholders were originally skeptical. Health Insight worked closer with us when they realized agencies were receptive to our incentives and approach to partnering. Agencies opened up to ur assistance when they realized they had autonomy in what would be selected and how it would be implemented, and when they noticed their patient indicators improving. The financial incentive opened the door to piloting activities agencies had interest in but no evidence of, and then expanded policies and activities without future funding.
All the IPCP checklist activities were meant to be sustainable beyond the funding that was available. The SLIDH team provided all providers and clinical staff with a flash drive that included all the necessary resources to continue educating their staff members and their patients through digital toolkits that also included pamphlets, handouts, and templates that were meant to be used and referred to in the future. Once completing IPCP checklist activities, healthcare providers and clinical staff learned to develop work plans and gained new skills to implement patient quality improvement activities in their settings that they can sustain on their own without facilitation of the SLCoHD. For example, providers and staff learned to query their health records to create patient registries by certain health conditions and learned how to utilize health record alerts which they can apply to new health conditions in the future.
Clinics and pharmacies established new workflow processes and policies that work best for their specific clinic patient population and those processes and policies are now part of clinical practices to improve patient's continuity of care for the long-term. Those that achieved their IPCP goals and experienced positive patient changes and results were motivated and committed to continuing to apply improved patient care projects in the future. To make sure agencies completed activities, and thus had funds for activities on their own, each organization received reimbursement only after all the activities were completed and proof of activity completion/reporting documentation were submitted. Therefore, these monies acted as an incentive and were not given as funding in order to achieve their projects nor to buy equipment or materials.
At this point, SLCoHD believes that stakeholders are committed to sustain the principles and practices of these improvement projects and have adequate resources, knowledge, investment, and skills to maintain similar projects after the initial funding. The SLIDH team strives to continue to offer IPCP checklists to new partners and continue to provide health related improvements to citizens of Salt Lake County.