Population Health Management

Submission Date: December 2012

Entry Type: Case Study

State/Territory Submitted on the Behalf of: Massachusetts

States/Territories Involved: Massachusetts

Domain Addressed:

Health Systems Strategies

Public Health Issue:

For effective implementation of EMR, practice workflows & reimbursement incentive schemes need to change. Must orient technology, care, billing systems toward prevention with emphasis on clinical interventions that save lives.

Project Objectives:

Improve clinical outcomes for people with or at risk for CD by implementing systems change.

Program Action:

This project tarets adults with or at risk for chronic disease .

A primary care Quality Improvement Specialist will assist practices to improve systems of care for patients with CD. Pilot a change tool that guides system level change for improved management of BP, chol, DM & tobacco. Assist & support practices to integrate all elements of the CCM by improving collection of accurate data, evaluating data to prioritize improvement, implementing changes using rapid cycle improvement model, spreading & sustaining system change.

Partners include:

MA Dept of Public Health (DPCP & HD&SPCP)

Southcoast Physicians Network

Data/Other Information Collected:

Improved clinical outcomes (aspirin use, A1c < 7, BP < 140/90, LDL-chol < 100, BMI assess, tobacco assess & intervene, lifestyle prescriptions), patient satisfaction surveys, key informant interviews of providers for behavior change

Impact/Accomplishments:

SPN contract completed, site assessment developed & piloted, QI coach hired.

Challenges/Lessons Learned:

Not all sites are using EMR, not all sites using EMR are using the same one

Next Steps:

Conduct site assessments & ACIC at each of 31 sites

Program Areas:

Epidemiology and Surveillance, Healthy Communities (general), Other

State Contact Information:

MA
Claire Blais
Massachusetts Department of Public Health
617-624-5422
claire.blais@state.ma.us

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