Site Visit - Cambridge Health Alliance

Hello attendees of the Cambridge Health Alliance site visit on 10/11! We would love for you to share key takeaways, learnings, and next steps from the site visit with the rest of the PHLN network! We ask that at least one member of your team that attended the site visit post here. All PHLN teams, feel free to comment and ask questions!

Please answer one or more of these questions:

  1. What is one of the most valuable takeaways you had from the site visit?

  2. What resource did you find useful? If you have a copy of it, please attach.

  3. What is a next step your team is planning to take as a result of what you learned at the site visit?

  4. Anything else you want to share?

The CHA site visit was packed with valuable information and learnings from across disciplines. A few key takeaways include:

  • Clinical pharmacy integration model, including 1 pharmacist: 10,000 patients, can successfully manage a wide range of chronic disease including diabetes, hypertension, COPD, and more. Clinical pharmacists are members of the care team, and are treated as providers with the support of other team members, a scheduling template, and direct lines of communication with PCPs.
  • The population health management strategy at CHA is well-developed and engages all members of the care team to address preventative health needs of empaneled patients. Each care team member is responsible for pulling lists and performing outreach on patients for metrics based on their role (i.e. clerks perform outreach for patients due for PAP smears), and then reporting out their progress at regular intervals. Staff take ownership over outreach responsibilities.
  • SDOH screening has been rolled out recently on a variety of domains (housing, food, transportation, utilities, employment, and more) and is collected on paper and then entered in the EMR by CMA staff. Patients who have a positive screen in any area are offered resources and receive a follow up phone call to help them navigate and obtain those resources.

Thanks @brubino for sharing your key takeaways!

What did others learn at the site visit? @chelsea_communicare @lynnetteb @melissa.bishop @sarah.cox @Myrna @lynette.harris

@tammy_cci has shared her key takeaways in an article posted on our website. Check it out here: 5 Things I Learned at Cambridge Health Alliance - Center for Care Innovations

Scheduling Templates

Social worker CHW role is scheduled at regular 30 and 60 minutes visits.

Pharmacotherapy schedule: The following information is provided by Monica Akus, PharmD, BCPS, DPLA, who is the Director of Pharmacotherapy Services at Cambridge Health Alliance. See below or download the PDF.

For initial planning I use this metric, then modify to actual volume/need:

  • 1 FTE: 10,000 patients on a panel = 8 sessions per week (3.5 hrs care each)

Pharmacotherapy Department Visit Types: tips for scheduling

Anticoagulation Management Service (AMS) – (warfarin patients)
Visit type / Who to schedule
RX AMS 15 (FU) / Follow up visits (test INR)
RX AMS 45 (EDU) / Initial visit (education and test INR)
Diabetes Management Service (DMS) – (diabetes patients, glucometer education, insulin education)
Visit type / Who to schedule
RX DIAB ED 30 / Follow up visits
RX DIAB ED 60 / Initial visit, glucometer/insulin educations
RX DIABETES ED 45 / *Not routinely used; check with clinic pharmacist
Other Services – (hypertension, hyperlipidemia, medication reconciliation, COPD rescue pack, inhaler education, travel health(Cambridge Family Health ONLY), etc)
Visit type / Who to schedule
RX CONSULT 15 / *Not routinely used; check with clinic pharmacist
RX CONSULT 30 / Follow up visits for hypertension, hyperlipidemia
RX CONSULT 45 / Initial visits, medication reconciliation visits (initial or follow up), travel health (CFH ONLY)

Some of the pharmacists do a mix of AMS vs. other services and block portions of their schedule for each throughout the day to make scheduling more efficient while others do not need to do that. They do this if they need to accommodate 15 min increments vs. 30 min increments. Some sites do not have an exam room and can’t do AMS unless they use the lab (CFH).

@brubino @chelsea_communicare @lynnetteb @melissa.bishop @sarah.cox @Myrna @lynette.harris @tammy_cci

A few of CommuniCare’s key takeaways were:

• Building a culture where everyone is responsible and invested in quality improvement metrics is key to improving population health. All team members are trained on PDSA model, understand the metrics they’re accountable for, and have a voice in quality improvement activities. Also, data is transparent and accessible.
• Pharmacists could be playing a larger role with drug therapy monitoring, individualized drug therapy counseling, and chronic disease management.
• Care Teams with multiple providers focus on co-management rather than Coverage
• MAs are trained phlebotomists – patients less frequently have to return for lab-only appts
• Individual care teams can test shifts/experiment with changing workflows for 1-2 weeks at a time
• Employee Wellness: Balint Group for Providers (monthly) and All-Staff (quarterly)

I added a new resource to the list of resources on the PHLN Portal from this site visit.

Dr. Meisinger shared with us the Care Needs Screening and SDOH presentation. This presentation describes how Cambridge Health Alliance uses their Connect-C and Connect-S screenings to then make referrals. The presentation also includes some workflows and responsibilities based on care team role.

@Communicare @LA_County @Neighborhood @SFHN @San_Ysidro