Alaska FQHC Quality Improvement Facilitator Coaching Project

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1 1 Alaska FQHC Quality Improvement Facilitator Coaching Project Tari O Connor, MSW Chief, Section of Chronic Disease Prevention and Health Promotion Alaska Division of Public Health

2 2 The QI Facilitator Coaching Project Provide QI process training and onsite coaching using the IHI Model for Improvement * Provide evidence-based resources for improving hypertension control Provide training for Team-Based Coordinated Care and PCMH Certification *Source: Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; IHI: Institute for Healthcare Improvement:

3 Goals of the QI Facilitator Coaching Project 3 1. To improve the % of patients with a diagnosis of hypertension and whose BP was adequately controlled (<140/90). 2. To establish a facilitated peer network of FQHC/CHC clinic staff and providers to allow a platform for sharing best practices and methods among the 29 Alaska FQHCs. 3. To increase the number of referrals to DSME (Diabetes Self-Management Education) programs for patients with diabetes

4 Methods to Achieve Project Goals 4 Use established QI processes, including: Electronic health record (EHR) data evaluation Coaching clinic staff to make process changes using Plan-Do-Study-Act (PDSA) process improvement cycles Adoption of best practice protocols for controlling high BP Million Hearts Guidelines and Tools AHA/ACC/CDC Guidelines

5 Why FQHCs? 5 Best, most specific Alaska data available for measuring blood pressure control Located statewide including many rural areas

6 Project Resources 6 CDC 1305 grant (State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health) CDC 1701 grant (Cancer Prevention and Control Programs for State, Territorial, and Tribal Organizations) ASTHO grant (State, Tribal and Community Partnerships to Identify and Control Hypertension) 6 18 State Medicaid Partnership CDC/Center for Health Care Strategies

7 7 Project sites

8 Evaluation - Data Sources 8 Process Measures Harvest Session for Cohorts 1 and 2 sites Program records Key informant interviews Quantitative Outcomes HRSA Uniform Data System (UDS)

9 Outcomes Hypertension 9 Population weighted average

10 Process Outcomes 10 Patient flow improvements Improved staff and patient engagement in management of hypertension and diabetes Improved effective use of EHRs Spread successful QI processes and other lessons learned to other clinics in the FQHC and to other FQHCs Lessons learned are being applied to diabetes and cancer focused process improvement work in FQHCs

11 Challenges 11 Problems with EHR functionality EHR transitions Clinic staff buy in and turnover Lack of staff knowledge about hypertension at some clinics Centralized training was not effective Shorter, onsite training was successful Virtual training being tested now

12 Lessons Learned 12 Training needs to be tailored to each specific setting, and address specific clinic needs On site training was critical to build staff skills and trust Length shortened from 2.5 days to 4 hrs w/ pre-assessment Engagement of clinic leadership is very important Assess and support basic skills, including internet access, using Excel, EHR functionality, basic QI terminology, selling QI early Recognize this work takes time

13 Contact Information 13 Tari O Connor, MSW Section Chief, Chronic Disease Prevention and Health Promotion teresa.oconnor@alaska.gov Janice Gray, RN, BSN Nurse Consultant II, Heart Disease and Stroke Prevention Section of Chronic Disease Prevention and Health Promotion janice.gray@alaska.gov Web:

14 14 Additional Information

15 Outcomes Cervical Cancer Screening 15 Population weighted average

16 Outcomes Colorectal Cancer Screening 16 Population weighted average

17 Outcomes Tobacco Screening and Intervention 17 Population weighted average

18 18 Additional lessons learned and recommendations Create opportunities for sharing tools and lessons across Alaska FQHCs Ongoing support and coaching from training providers maintained motivation and momentum Create a plan to address staff turnover Assist to address health data loss Address QI within tribal health system context

19 Project Partners 19 Alaska Primary Care Association Yukon-Kuskokwim Health Corporation Council of Athabascan Tribal Government Seldovia Village Tribe Camai Community Health Center Alaska Island Community Services Yakutat Tlingit Tribe Native Village of Eyak Cross Road Medical Center Girdwood Health Clinic Eastern Aleutian Tribes Iliuliuk Family and Health Services

20 Deaths per 100,000 Population US, Alaska Hypertension Death Rates, US Black United States Alaska 300 AK Black AK AI/AN All Races Non-Hispanic Black Non-Hispanic White Hispanic American Indian & Alaska Native Asian and Pacific Islander Age 35+, All Race, All Gender, Source: CDC Interactive Atlas of Heart Disease and Stroke

21 Percent of Adults with HTN 21 Hypertension Prevalence among Adults: Alaska and US, (BRFSS) 50% 40% 30% 20% 19% 22% AK US 31% 28% 10% 0%

22 22 Hypertension Prevalence among Adults: Alaska, Select Groups, 2015 (BRFSS) Women Men White Alaska Native African American Poor Near Poor Middle/High 0% 10% 20% 30% 40% 50% 60% 70%

23 23 Source: U.S. Marshals Service, District of Alaska

24 Expanding Access to Healthy Strengthening Rural Communities through Food in Rural Healthy Communities Food Access John Weidman The Food Trust October 1, 2014 Karen Shore, MPH Director, The Food Trust Princeton, Kansas

25 The Food Trust Ensuring that everyone has access to affordable, nutritious food Increase availability and affordability of healthy foods Promote healthy food choices and good nutrition Create demand for healthier food in communities Advocate for better food policies

26 Where We Work Regions of particular focus for this convening

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28 Impact on Rural Residents Greater travel time to shop Healthy foods harder to find; less healthy options dominate Higher cost of food Diminished quality especially of fresh items Loss of jobs, economic engine Lack of community hub Diminished community resiliency Poor health and well-being High healthcare costs

29 A Comprehensive Approach

30 Across Rural and Urban America, Grocery Stores Are Business Anchors and Community Assets Markets for Local Farmers & Ranchers Convenient Sources of Fresh Food Partners in Fight Against Childhood Obesity Local Employers All Age, Skill, and Ability Levels Healthy Food Retailers Business Anchors and Leaders Convenient Sites for Health Screenings Catalysts for Community Safety & Revitalization Community Gathering Places Bardstown, Kentucky

31 A Grocery Store Is Sometimes One of the Only Places Left That Regularly Employs People with Disabilities Source: Bangor Daily News, April 3, 2017,

32 Grocery Stores Are Also Critical Links in Jobs Training and Workforce Development Programs Source: EITCOutreach.org, Work Training for Individuals Released from Prison 2017 Source: Pride Industries, Employment for Veterans 2015

33 Rural Food Stores

34 Healthy Food Financing

35 Examples of HFFI-Funded Projects

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37 Key Recommendations 1. Launch new or invest in existing HFFI funds. 2. Support healthy food retail efforts, such as healthy rural store initiatives (see appendix). 3. Boost statewide TA and shared resources to support healthy food access initiatives. 4. Maximize access to SNAP and WIC for eligible residents.

38 Thank You! Karen Shore, MPH

39 APPENDIX

40 Health Influencers in Rural Communities Geography Occupation Infrastructure Demographics Digital Divide Access to Services Social Capital Political Voice Crosby, Wendel, Vanderpool, and Casey. (2012) Rural Populations and Health: Determinants, Disparities, and Solutions.

41 Deeply Held (and Often Incorrect) Beliefs About Rural Communities Homogenous Racial/ethnic Religious SES Grow own food Affordable to live Little population change Not in need of outside help Needs are being met by other systems Very far from cities

42 Many small food stores in rural areas that are not part of a Healthy Rural Store Initiative face challenges in being successful businesses and supporting the community s access to fresh, affordable foods Fresh items are hard to find or absent altogether The store has outdated or broken equipment, which makes attractive merchandising difficult and drives up utility bills The store is struggling to stay in business Chips, candy, and pastries are among the only foods sold at this convenience store Full display of chips but mostly empty grocery shelves at this mom-and-pop

43 But small stores in rural areas often DO serve as a community hub or general store, which chain convenience stores and dollar stores typically do not Seating for cup of coffee or meal; community gathering spot Clothing Work boots and shoes Health & beauty aids Household items Auto repair items Cookware Fuel sales Post office Remittances Mini-hardware store assortment Hunting/fishing supplies Religious items The list goes on!

44 Why Launch a Healthy Rural Store Initiative in Your Community? Easier access to good, fresh foods Part of comprehensive farm and food strategy Stores are convenient and residents may stop in more frequently than markets farther away; part of daily life Existing infrastructure Support local economies Community hubs Opportunities for program linkages (e.g., cooking classes, blood pressure screenings) Business anchors New markets for farmers and ranchers

45 Healthy Small Stores - Vision Offer a good variety of nourishing, affordable foods to help make it easy for people to make better choices for themselves and their families; support SNAP & WIC when appropriate Allow fill-in trips with milk, eggs, fruits and vegetables, whole grain breads, and other grocery staples Serve as community anchors/hubs and provide opportunities for community engagement and access to services Help promote a sense of community, and encourage the good health and well-being of all residents Provide the resources and expertise needed to support store owners in making in-store changes in a way that makes sense for their businesses