The goal of the project was to connect public health, the regional accountable care organization, and local primary care providers in an effort aimed at coordinating practice-level quality improvement (QI) projects with a community-based education campaign intended to improve practice performance while simultaneously increasing patient awareness of their responsibilities. In doing this we sought to leverage the skills and experience of each entity in a coordinated, synergistic approach. There was an intent to eliminate duplication of effort and competition among the partners, especially for health care provider time and attention to identified issues. There was also intent to reduce, if not eliminate, mixed and competing messaging related to the chosen health care metric.
CCHD has long served as the county's chief health strategist, convening partners from all sectors, providing the traditional public health services of a local public health department but also leading the local public health system in policy, systems and environmental changes (PSE) for well over a decade. Well established, existing relationships with health stakeholders across the area affords CCHD access to residents through a variety of programs and opportunities offered by partners. In addition, the agency's multidisciplinary staff enhances its ability to implement complex projects that necessitate health knowledge, political savvy, promotional skill and fiscal responsibility. CCHD served as lead coordinator for this pilot project, offering its partner facilitation and public health detailing skills, the ability to reach the community at large, and experience in crafting messages to the partnership. CCHD staff dedicated to the project managed practice specific projects (coordinating visits and routine check-ins with practices, assisting practices in overcoming obstacles, convening partners, etc.), maintained awareness among partners, completed evaluation activities and have taken a lead role in disseminating project results and outcomes, among other activities. In total the project period lasted 10 months, from November 2018 to September 2019.
To apply this approach, CCHD and the Adirondacks ACO convened in mid-November 2018 and considered a number of current population health issues and potential topics. The pediatric-to-adult health care transition was selected as the pilot-project topic, based on metrics identified by the ACO as needing improvement; specifically, attendance of well visits by persons 7-11 years, 12-19 years, and 20-44 years of age. Once the topic was identified, CCHD and the ACO worked together to develop project objectives, a timeline, and to identify evidence-based resources available for use in the project. Got Transition® and the Center for Health Care Transition Improvement, a cooperative agreement between the Maternal and Child Health Bureau and The National Alliance to Advance Adolescent Health, was identified as a key resource for this project. The program outlines Six Core Elements of Health Care Transition that define the basic components of health care transition support, offers validated qualitative and quantitative assessment tools, and provides a wealth of supporting materials.
Project process objectives included: completing pediatric to adult health care transition QI projects at 100% of targeted health provider practices; progress in meeting the Six Core Elements of Health Care Transition demonstrated by at least 80% of targeted practices; participation in the community education campaign by 100% of Clinton County school districts; sharing of community campaign messages through 90% of targeted partner organizations social media platforms. Project outcome objectives included: increasing compliance with the wellness visit by 5% across all payers; and wellness visit compliance reaching the 90th percentile for all payers.
In December 2018, CCHD and the ACO shared an overview of the initiative, including timeline and project objectives, with local medical providers at a recurring Pediatric Initiative Meeting; pediatric, family, and adult providers, medical staff and school nurses were invited to attend. Eleven medical practices participating with the ACO were identified as target sites for our pilot project, including 3 pediatric practices, 5 adult practices, and 3 family practices. During the months of January and February 2019, CCHD and the ACO completed a 15 minute staff in-service with each of the eleven targeted practices, at which time practices were asked to identify a practice champion team lead and complete baseline assessments. Once completed, ACO staff collected these baseline assessments during their regularly scheduled visits.
During February to mid-March 2019 the ACO and CCHD reviewed baseline assessments and identified potential QI projects and available resources for each practice. Of the 11 medical practices approached, 8 chose to participate; 2 pediatric practices, 3 adult practices, and 3 family practices. At the end of March 2019, participating providers were invited to reconvene at a Pediatric Initiative Meeting to discuss baseline assessments as a health care community, and identify potential barriers to project implementation. In addition, providers were asked what key messages adolescents and their parents in our community were lacking. From March to May 2019, 1:1 meetings were held with each practice champion and in-house stakeholders, as practice-specific projects were identified and implemented. CCHD and the ACO worked with practices to integrate the Six Core Elements in a way that supported each practice's own workflow and practice needs. For meetings, CCHD and ACO staff coordinated schedules so that at least one representative from each agency was present at all meetings with practices. Throughout the project period, ongoing technical assistance was provided to practices. CCHD and the ACO communicated frequently with each other during this period, primarily by email and telephone, as well as in-person before and after meetings with practices.
As practice-level QI projects were underway, CCHD staff developed a community campaign, highlighting key messages identified by providers and utilizing resources from Got Transition®. CCHD and the ACO recognized that beyond establishing policies and implementing best practices at the practice-level, the initiative required that patients, including parents and adolescents, be informed and understand their role in taking charge of their health. A blog and engaging social media messages were created by CCHD and shared with the public via Facebook, Twitter and Instagram. CCHD utilized existing relationships and contact information with school nurses at all middle and high schools in Clinton County to seek their participation in the project, primarily through the sharing of campaign messages with their students via social media. CCHD also collaborated with the Communications Department at the State University of New York (SUNY) at Plattsburgh, who developed a series of Public Service Announcements (PSAs) for the project. Staff presented the project to students mid-April 2019, and just over one month later, received 8 finalized carefully curated quality PSAs, at no cost. These PSAs aired on local radio stations through in-kind time, and were made available to community partners and medical practices. Lastly, CCHD created individualized campaign materials for medical practices as requested, such as postcards reminding young adult patients to schedule their annual well visit.
Practice-level QI projects were completed between May- June 2019, and qualitative and quantitative post assessments were collected from practices through August 2019. In September 2019, CCHD and the ACO formally met to discuss project successes, barriers and lessons learned. Since project completion, this information has been shared with a number of groups, including with health care providers at a Pediatric Initiative Meeting in late September 2019, with all Clinton County school nurses at the annual School Nurse Professionals Meeting hosted by CCHD each fall and with the ACO's regional practice transformation workgroup in December.
There were minimal costs associated with this project. The CCHD used three core staff to collaborate with the ACO; recruit and complete staff in-services and 1:1 meetings with practice champions; provide ongoing technical assistance to practices; present periodic project updates to key stakeholders; develop and implement the associated community campaign; and share project outcomes to key local and regional stakeholders. There were also minimal costs associated with printing and developing practice-specific guidance materials. Overall the biggest commitment was time, not materials. An estimated total of approximately 180 hours of staff time were devoted to this project over a 10 month timeframe. Position responsibilities for all involved staff include community partner engagement, education of local provider practices, contributing to sustainable and effective health system change work and disseminating health messages to the community. Therefore, CCHD fully supported the investment of staff time into this project and if such time was not dedicated to this collaborative initiative, said time would have been devoted to other similar but less collective efforts.