CP28 - Integrating Continuous Quality Improvement with Health Center Based Events

Poster Type: Innovation

Category: Quality of Care and Quality Improvement

Issue or Challenge: Care For the Homeless's business model integrates our internal Continuous Quality Improvement (CQI) data and goals and our Population Health events in order to provide patient-centered, evidence-based care to a socially and medically complex population. We use this model to identify gaps in preventative health services, and engage a population that disproportionately relies on emergency care in preventative screenings.

Description of Innovation: Through this model we use a data informed approach to population-wide outreach, engagement, education, and care. Our CQI goals are tracked closely using the Center for Primary Care Informatics (CPCI) platform, which allows us to monitor real time progress on a site by site basis. CQI information is shared with our Population Health Management Team and drives the focus of site-based health events. These events bring focus to a health topic among the patient population and generate a high volume of provider visits and education specific to that topic. Outcomes from these events are tracked, and through CPCI we can measure changes in our CQI measures following Population Health events. These CQI driven events include enhanced outreach, patient engagement, and education on a health topic, such as diabetes, immunizations, or heart disease. Patients are seen same day by a provider for a screening and/or visit related to the selected topic, for example a point of care A1C test and a nutrition visit for a diabetes focused event.

Impact or Result: CQI-driven Population Health Events have shown to increase the number of daily clinic visits; on average there is a 91% increase in the number of billable visits at a health center during a Population Health Event, as compared to a day without an event. Population Health events also increase the number of screenings measured through quality indicators. For example, an internal CQI indicator is the percent of eligible patients who receive a cervical cancer screening. In January 2019 the Population Health team hosted two cervical cancer screening events, and in the month of January there was a 36% increase in the number of cervical cancer screenings conducted as compared to December 2018. Between July and December 2019 the Population Health Team hosted six childhood immunization events, and in this same time period we saw a 14.3% increase in the Childhood Immunization Status measure.

Replicating this Innovation: Our Population Health events follow a Patient Centered Medical Home model; they are data driven, patient-centered, and use a team-based approach, integrating the Population Health, clinical staff, Outreach Specialists, and the CQI team. Using these principles, other organizations can host similar events based on the needs of their patient population.

Author(s):

Isabel Odean, MPH, Quality Improvement and Data Manager, Care For the Homeless