Data Tools & Reporting to Close Gaps in Care

This affinity group includes @Salud @Venice @Ravenswood. Please feel free to share your group’s progress and updates below!

Hi Everyone, this is Ravenswood Family Health Center (RFHC)'s PHLN team. RFHC is located in East Palo Alto (Bay Area). Our team consists of our COO, our Quality & Project Management Officer, our Front Office Operations Manager, our Senior Data Analyst, and myself: Grant Writer/Health Program Planner. We may have a new Panel Manager joining our team in the near future.

We are working on using data to improve panel management of out-of-care patients whose insurance has lapsed.

We look forward to working with all of you!

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Hi @AnnieWuRFHC! Welcome and thanks for the nice intro. It’d be great to have other teams share intros as well below!

Hi everyone! We are Salud Para la Gente, located in Watsonville on the Central Coast near Santa Cruz. Our team includes myself as the Director of Health Info & Population Health; @acontreras who is our PCMH Specialist; @amy_saludparalagente who is our Director of Patient Services; and @dobinger as our Director of Nursing. We are working on improving our data transparency as part of developing & implementing various population health/clinical quality reports beginning with our colorectal cancer screening reports. We hope to build useful reports that our teams can use to generate actionable ideas. Looking forward to meeting and talking further!

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Hi everyone! I am excited to be your point person for our affinity group. I included notes and action items from our call on Tuesday, April 30th.

  • Salud Para La Gente: Mai shared that they’re building on their year 1 focus which was on strengthening their care teams, structure and roles using PODS. In year 2 they are working on strengthening pop health - inreach and outreach - by starting with colorectal cancer screening. They’re doing rapid cycle improvement projects, about 4 months per clinical measure. Challenges/questions - how to share data in a useful and transparent way? Any ideas or example?

  • Venice: Darcie, Susie and Meghan shared that they are trying to integrate their their patient visit planning/huddle tool into their EHR, NextGen. Challenge/question - getting staff together to work on the project, specifically MAs, when they are working with patients and it’s hard to pull them off the floor.

  • Ravenswood: working on connecting patients with insurance lapses to insurance or removing them from their active patient panel. Challenge/questions: lost their panel manager and wanting to learn from others how they manage their panels specifically for this population.

Action items

Next call will focus on effective huddles and tools, and how tools are integrated into the EHR. Each team in our affinity group will share on next call their approach to huddles and the previsit planning tools they use. Tammy will recruit an additional organization doing this well to join the call.

Another topic of interest for a future call is sharing reports, tools, and approaches for closing gaps in care. Each team in the affinity group would share their information.

Tammy will schedule another call for early July. Please read @mbuiduy; @AnnieWuRFHC; @Ravenswood; @Venice; @Salud

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Hi there @Venice, @Ravenswood, @Salud !

Thanks for joining today’s affinity group call and a special thank you to Melissa @melissa.barajas and Claudia @clalvarez for joining us. Today’s topic focused on optimizing planned care/in reach activities through huddles. Please post your insights from our affinity group on our forum. We had representation from all three of our teams.

Action items:

  • decide on our next topic for discussion sometime in September. Please share on the forum your suggestions for our next topic within the area of closing gaps in care through in-reach/planned care or outreach activities.

Thanks everyone!

Hi Tammy,

Will the slides presented during the discussion be shared with the group?


Hi Maribel
Melissa and Claudia agreed to make their slides available. Attached find Melissa’s. @clalvarez Claudia, I don;t have a copyPHLN Huddles (002) Neighborhood Presentation.pdf (271.0 KB) of your slides. Can you attach them? Thanks, Tammy

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Hi All,

I apologize. Here are our slides.Huddle Presentation for Affinity Group_071719.pptx (573.5 KB)

Hi All,

Does anyone have protocols for retinal photos that you could share?