primary care innovation through research, training and consulting

primary care innovation through research, training and consulting

primary care innovation through research, training and consulting

primary care innovation for the underserved through research, training and consulting

primary care innovation for the underserved through research, training and consulting

primary care innovation through research, training and consulting

WINTER

2015–16

Last month CHC kicked off a new agency-wide initiative to be-come a center of excellence in the provision of care to the LGBT community with a Grand Rounds presentation given by Dr. Har-vey Makadon. This effort will involve CHC employees from all areas of the health center. Several projects at the Weitzman Insti-tute will help us to achieve this distinction and give us the opportunity to work with other centers across the country. First off, the Ryan White Microsystem team led by QI Coach Grace Capreol and team leader Dr. Marwan Haddad are conduct-ing PDSA cycles to help determine the best way to capture and record informa-tion on each patient’s sexual orientation and gender identify (SOGI). Their work conducting small tests of change will help us to figure out not only how and where to store the data, but how best to ask the questions in an affirmative manner that max-imizes the chance to accurately capture this information.

In conjunction with this work, the QI data team is developing ways to capture quality of care data for LGBT people to make sure that we are providing them with effective, evidence-based

care. The Project ECHO® team is in the final phases of develop-ing a brand new Project ECHO® LGBT which will allow primary care providers from CHC and other health centers across the country to join twice monthly sessions to present cases and learn from each other about LGBT healthcare. Education and training

specialists at Weitzman are designing a learning collaborative that will engage ten health centers, including CHC, in a year-long project to implement best practices for LGBT healthcare. Lastly, we plan to offer access in the coming year to eCon-sults with an endocrinologist specializing in transgender healthcare.

The Weitzman Institute is committed to inspiring innovation in primary care and in so doing, improving quality and pa-

tient outcomes. This project demonstrates what Weitzman is all about. To improve care for our LGBT patients, will use some of our most effective tools, from Project ECHO® and eConsults to front line PDSA cycles to achieve our goals and bring the highest quality of care to a special population of patients that deserves nothing less.

Winter 2015–2016 Highlights

A Letter from the Director by Daren Anderson

Daren Anderson, MDVP/Chief Quality Officer,

Director of the Weitzman Institute

Scan with your Smartphone

for more information

SOGI Team Holiday Event

What’s SOGI?See article in this edition.

Look inside for information on exciting programs,

skill and leadership training, and practice-based research

primary care innovation for the underserved through research, training, and consulting

CHC Receives $274,422 Grant to Support Project ECHO® Behavioral HealthWe received grant funding in the amount of $274,422 from the Connecticut Health and Educational Facilities Authority (CHEFA) to support Project Extension for Community Healthcare Outcomes (Project ECHO®) Behavioral Health (Project ECHO® BH). The project uses innovative technology to provide critical increased access to treatment and better outcomes for children and adolescents in school-based clinics across Connecticut. This grant is one of only two grants awarded through the highly competitive Targeted Investment Program in 2015.

Over 1,100 eConsultsTo date, we have over 1,100 eConsults (1,173 to be exact; of those over 1K are CHC’s). In addition to cardiology and dermatology, we also have ophthalmology, pain manage-ment, endocrinology, and orthopedics by the end of January. In Maine, we now have launched cardiology, dermatology, endocrinology, and neurology.

We will use some of our most effective tools

to achieve our goals and bring the highest quality of care to our

LGBT patients.

The is a program of

CHC Project ECHOists: Adriana McCormick, APRNAlan Ruiz, MDAlicia Dodson, MDAlicia Petit-Irizarry, RNAllison Hill, RNAllison Levin, RNAndrew Yim, APRNAria Swan, RNAvery Bozek, RNBernalda Delgado, RNBozena Roberts, RNBrenda BeauchampBrendan Green, RNCara Severson, APRNCharles Melvin, APRNChelsea BoskaChristine Schwartz, RNCristina Hewes, RNDan Miller, MDDan Wilensky, MDDaniel BryantDaphne Braden, APRNDebhra Tobin, LPNDelphine Hyppolite, APRNDinnah Inventor, RNElaine Morrissette, RNErin Kampa, APRN

Erin PooleErin Roberts, APRNEunice Rivera-

Miranda, PsyDFarqan Khan, APRNFelicia Seay, APRNGabriella Gellrich, MDGail Fasciano, RNGeovanna Fiallos, APRNHazel Groce, APRNHelen Liu, MDJamie Stevens, APRNJanet NoyesJason Evans, PhDJenna Stephens, PsyDJennifer Martin, RNJose Silgado, PhDJulie Bordua, APRNKassandra McGrab, RNKedemah Johnson, RNKelley Sanok, RNKrishna Kothary, APRNKristen Hewitt, RNKristin Haney, APRNLeena Kamat, MDLeonela Espinal, RNLucy Golding, RNMara Bennink, RNMarat Gitman, MDMargaret LaPointe, RN

Maria Barros, APRNMaria LorenzoMariana Salas, MDMaryAnne Harmon, APRNMelissa Castillo, PhDMichelle Kusnir, RNMonte Wagner, APRNMyrna Velazques, RNNatalie Bycenski, RNNatasha Ferguson, MDNetmari Vazquez-

Vargas, RNNichole Mitchell, APRNPatricia Mik, RNPatrick Murphy, RNPaulina Miklosz, APRNRebecca Mccarron, RNRebekah Smith, APRNRochak Pradhan, RNSabine Cayo, RNSaleha Chaudhry, PhDSalvatore CappettaSarah Almonte, RNSarah Frieberg, APRNSarah Regan, APRNSharita Rivers, RNSheryl Johnson, RNStephanie Ferris, RNSusan Arvan, MDSuzanne Burgess, RN

Tonya Smith, APRNVeronica Kuritzky, APRNViana Turcious-Cotto, PhDVicki Carter, PsyD

QI Team Members: Adriana RojasAgi EricksonAislinn EdwardsAldon HynesAlicia DodsonAmy TaylorAndrew YimAnna RamosAvery BozekBerwyn KelleyBethany SchmidtBev ColemanBrendan GreenBridget TeevanCarl LecceCarmen AlvarezCaryl GreccoChelsea BoskaChristopher HaleCindy SaezClarissa CruzCliff Briggie

Courtney TarasiewiczCraig RosenbergCristina HewesDan MillerDara RobinsonDaren AndersonDave GuggenheimDeb FariaDeb WardDipak PatalDoug JanssenEd BiancoElaine MorrissetteErika SparksGrace CapreolHannah BajorHartmut DoerwaldtHeather Crockett-

WashingtonHeather ShallcrossIdiana CelezJamie StevensJane HylanJen BarrettJill Day-AllegroJohn MonroeKai PerryKara EllisKaren MessierKasey Harding

Kasey Harding-WheelerKate PattersonKatherine TaverasKatie JewittKatie LainasKerry BamrickKrishna KotharyKristy WellsLirianie ChevereLori ClavetteLucy GoldingLynn TaylorMandy LambMara BennickMarat GitmanMargaret FlinterMaria LorenzoMaribel AcevedoMarwan HaddadMary BlanksonMegan HansenMelissa ThibeaultMirella MujcinovicMolly SherwoodMonte WagnerMy Phuong TongNabil GomezNat HolmesNatalena FantozziNatalie Bycenski

Nick CiaburriNicole SeagriffOmar PerezOvanes BorgonosPam LaraPatricia MikPatti FeeneyRebecca BettingerRebecca RobothamRenaldo BertieRita SobierajSally LastrinaSarah ShoemakerSlyvia LunaSydney KennedyTara SantamariaTara TremblayTara-Lee DavidsonTichianaa ArmahTierney GiannottiTim KearneyTim SpagnolaTracey Pierre-LouisTyler PhillipsVanessa HendersonVeena ChannamsettyYvette Highsmith Francis

Training | Research | Quality Improvement

Eliza Cole

Kim Citron

Special Recognition Eliza Cole has been a Clinical Microsystems Coach since 2013. Currently coaching the Me-riden Prenatal Microsystem team, Eliza is a strong advocate for staff with a dynamic and positive approach to problem solving and team building. Utilizing quality improvement tools and strategies, Eliza has been able to support and coach her team as they transform the systems and working environment from the use of fragmented intradepartmental systems into a united streamlined process which has increased overall patient volume by 1,055 over the previous fiscal year. The team has also redesigned the Prenatal Pass-port for more effective communications between Community Health Center, Inc. (CHC) and the hospital. Eliza has not only been observed as a leader and quality improvement champion by her team, but also recognized by her peers and management team.

Meg Wright has substantially contributed to the success of the eConsults program. From the first touch point within the process, Meg consistently demonstrates a level of care and organization to assure all inquiries and responses are appropriate and efficient within the designated time requirement. Meg not only supports the process of eConsults, she developed workflows, helped with implementation of electronic transfer and assisted with the utilization of the SafetyNet Connect platform. Meg also assists with training and supporting Providers and Medical Assistants in the use of eConsults. Meg amazes the team every day with her excitement and energy to test new ideas. Meg truly has a commitment to innovative care and a dedication to the quality of processes within CHC.

In December 2015, Kim Citron secured a $50K grant to support a trauma and diabetes model she created: TraDICaM (Trauma and Diabetes Integrated Care Model) from the Connecticut Health Foundation. The grant is focused on the development and imple-mentation of the TraDICaM in Middletown. This care coordination-based program aims to enroll 150 patients that have both a trauma history and a diagnosis of diabetes and will bring together clinical staff from all disciplines (medical, behavioral health, nutrition, etc.). TraDICaM will also increase collaboration and self-efficacy among providers and will improve the health outcomes for the patients involved in the program. It is programs like these; developed from the innovative minds of those such as Kim Citron that help improve the quality of care for the patients at Community Health Center, Inc.

Working Together for Positive ChangeCHC and the Weitzman Institute engage staff at all levels of the organization to streamline processes and improve overall patient outcomes. Their hard work and dedication is recognized as the key components to improving the lives of our patients as well as our employees. The individuals listed below have made a positive impact on each of the initiatives they are involved in. Thank you to all of you, who strive to make our organization stronger by contributing and further developing your skills, working in high performing teams and always advocating for our patients to receive the best care possible.

WINTER

2015–16

Kudos to our dedicated staff for their contributions

to CHC quality improvement

teams, events, and projects!

The is a program of

Coming soon!

MICROSYSTEMS

2.0We listened to your feedback

and are in the process of enriching

Microsystems at CHC.

Stay tuned!

Meg Wright

BRIG

HT

IDEA

S

FROM INNOVATIVE THIN

KERS

Ryan White Microsystem working to incorporate SOGI data into everyday practice at CHC

Providing Care that is Relevant, Specific, and Compassionateby Grace Capreol The term SOGI (so-jee) stands for Sexual Orientation and Gender Identity, critical factors to providing the best care for our LGBT patient population. Community Health Center, Inc. strives to create a welcoming environment for all patients and deliver the highest quality care possible.

The Ryan White Microsystem in Meriden has taken on the challenge of incorporating the collection, dis-cussion, and electronic entry of SOGI data into everyday CHC practices. With guidance from the Fenway Institute, the team developed a 4-question survey that the Medical Assistant (Omar Perez) would hand to patients prior to meeting with their provider (Dr. Marwan Haddad). Patients were asked to fill out the form and discuss it with Dr. Haddad at the start of their visit. During a 4-week period, the questionnaire was given to over 100 patients with a current and complete SOGI history. The team realized some terms needed to be translated to Spanish and learned new characteristics about patients who had been in their care for years.

The largest barrier to the routine collection of SOGI data is efficient electronic entry. Appropriate use of SOGI information affects patients at every point of contact, yet certified EHRs still do not provide appro-priate fields for documentation of SOGI data. Transgender status is not accommodated, nor is preferred pronoun or even preferred name in some systems. Currently, the team is entering data in structured demo-graphics fields of eCW, but these data are difficult for clinical team members to find quickly. Fortunately, a time study showed that though the provider was able to provide SOGI responses within only 35 seconds, the Medical Assistant took an average of 1.5 minutes to enter the data into the demographics fields in eCW.

The next rapid cycle improvement test, or PDSA, will focus on entering information into the social history section of the patient chart, use of a smart form and structuring the data into social history. We also envision these data points to be part of the planned care dashboard. There is still much work to do in standardiz-ing and expanding this process across the agency, especially integrating with NOVO, a scripted practice management application developed by CHC for our front-line teams. However, we are excited about the patients we have already worked with and have seen an improved patient-practice relationship through the Microsystem team’s work.

631 Main Street, Middletown, CT 06457 | www.weitzmaninstitute.com | Facebook/CHCInc; Twitter(@CHCConnecticut)© Community Health Center, Inc. 2016. All Rights Reserved.

Community Health Center, Inc. (CHC) received a National Cooperative Agreement (NCA) to address the most fundamental need of health centers now and for the coming decades: a clinically expert, deeply committed staff representing all roles and disciplines in primary care that is trained to a high performance model of team-based care. To address this need, CHC will support your health center through education, assistance and training in the following areas:

1.) Transforming Teams• Join webinars where national experts will share their experience implementing and improving the team-based model of care. During these sessions

learn how to collaborate interprofessionally, use data to plan care, evolve nurse care coordination and complex care management, integrate behavioral health, and engage your patients and measure improvement.

• Enroll in a learning collaborative to launch team-based care at your health center. While participating in the learning collaborative, receive expert training to overcome obstacles like change fatigue, rewriting role descriptions, communication patterns, and redesigning your office to support the care team. Take advantage of technology—learn how to get the most out of your EMR, and collaborate with your IT department to create clinical dashboards.

2.) Training the Next Generation• Join webinars to learn how to host health professions students and trainees at your health center. Discover how to obtain affiliation agreements,

identify resources needed, successfully on-board, train preceptors, evaluate, and more.

• Join webinars to learn about what it takes to kick start post-grad residency programs. Explore the key elements of a residency program: costs and ROI, structure, impact on your health center, and more.

• Enroll in a learning collaborative to develop residency programs at your health center. Experts will personally guide you through planning and imple-menting a residency program at your health center.

How to ParticipateThese services are available free to you. The webinars are available to any interested health center. Webinar participants are able to access Zoom easily from an iPhone, laptop, desktop, or iPad without any fees or licensure on your end. To participate in a learning collaborative after the webinars have concluded you’ll be asked to take part in an application process. For more info on how to participate, or to receive updates on this program, send an email with your contact information to NCA@chc1.com and you will receive all necessary communications about this program.

CHC Awarded National Cooperative Agreement

NCA Clinical Chiefs

NCA Planning Meeting

In It To Quit (I2Q); CHC’s newest smoking cessation program, launched November 17, 2015 and with a goal of 750 has already enrolled over 125 patients across all twelve sites with 625 left to meet the program goal. Patients who enroll in this one year program are assisted through a series of options to help them quit within two months. These patients also have access to a suite of clinical services which include medication options to assist with quitting, one on one nurse visits focused on motivational interviewing, a CO breath-alyzer test and a Behavioral Health visit for individual or group counseling.

The I2Q patients are randomized into either control or intervention groups. Control group patients have access to these services and are asked to come to the clinic 2, 6, and 12 months after enrollment to complete smoking cessation verification testing. They receive $20 in rewards for each testing visit completed, regardless of results.

Intervention group patients have access to the same clinical services and an on-line plat-form called stickK. StickK allows patients to report smoking status, sign up support-ers and journal about their cessation journey. Patients can accumulate points through website interaction and clinical visits. A cessation test visit takes place at 2 months. If the patient passes the test, they earn an additional $200. If they fail the test, they lose any points they accrued. Some intervention patients are offered commitment contracts based on a promise to be smoke free at a 6-month test.

I2Q not only involves research staff, but incorporates employees from every depart-ment at Community Health Center, Inc. including Medical Assistants, Providers, Nursing, Dental, Patient Service Associates, Facilities, Business Intelligence, and Information Technology. This collaboration of all departments at CHC has made this project a suc-cess so far and provides a solid foundation of this initiative for motivating our patients to quit smoking.

I2Q not only involves research staff, but incorporates employees from every

department at Community Health Center, Inc.

Weitzman Institute Launches In It To Quit (I2Q), a new Smoking Cessation Rewards Program by Rachelle Jean-Paul

631 Main Street, Middletown, CT 06457 | www.weitzmaninstitute.com | Facebook/CHCInc; Twitter(@CHCConnecticut)© Community Health Center, Inc. 2016. All Rights Reserved.

The is a program of

WINTER

2015–16New Project

12 SITES

125+PATIENTS ENROLLED

Patient Service

Associates

Medical Assistants

Nurses PCPs Behavioral Health

Providers

Dietician Facilities IT Business Intelligence

Since 11.17.15 Launch: