Our first Meet the Program blog series focuses on the Safety Net Care Coordination Initiative, the fourth phase of P² Collaborative's signature project – the Aligning Forces For Quality (AF4Q) initiative funded by the Robert Wood Johnson Foundation. We talked about it with Christine Kemp, P²’s Community Health Improvement Coordinator.
Tell us about the initiative. What kind of day to day activities is P² involved in?
We work with eight primary care practices in the region that serve the un-and-underinsured on improving diabetes outcomes through different mechanisms of care coordination. Patients often struggle with poor diabetes control which results in costly care and adverse health effects. P² helps practices implement sustainable ways to manage care for their patients with diabetes.
Day-to-day activities include collecting monthly data reports from practice Electronic Health Records (EHRs) to monitor the health statistics for people with diabetes, tracking those trends across time, working with practices to improve outcomes and meeting with practice leadership or care coordination staff on a monthly basis to learn about challenges or struggles and offer tailored solutions to meet those needs.
What has been the biggest struggle or challenge faced thus far with this project?
Practices have struggled with the challenges of using their EHRs, but have improved greatly over the past few months. We are really thankful for the great effort they have put into making sure this project works for them.
What is something you’re proud of regarding this project?
After listening to practice staff and learning that they wanted to be more engaged with the project, we completely transformed our project management structure. We launched bi-monthly workgroup meetings to dive more in-depth in what’s going on within these practices. Staff has been able to take what they’ve learned in these work groups, make changes, and improve care for their patients as a result. One of our practices, The Resource Center, used the workgroup as a catalyst to start a new and innovative technique to actively target patients at risk for diabetes complications. Patients meet with special diabetes staff to get personalized attention to their needs.
You can read more about the Safety Net Care Coordination Initiative here.