NACHC's Care Teams Digest: Clinical Innovation Showcase Winners

Clinical Innovation Award Winners Special Issue

In August, NACHC along with partner Community Health Ventures opened submissions for its first Clinical Innovation Showcase. Twenty-eight health centers, Primary Care Associations (PCAs), and Health Center Controlled Networks (HCCNs) submitted applications. The competition offered a platform where clinical care teams could share unique and impactful initiatives that incorporated some or all of the Quintuple Aims—improved health outcomes, improved staff and provider experiences, lower costs, and equity.

This issue highlights our top three winners: AllianceChicago, AltaMed Health Services, and Oak Orchard Health. Each received complimentary travel and conference fees to the Financial, Operations Management/Information Technology (FOM/IT) conference and were acknowledged with an award during the Clinical Innovation Showcase ceremony. The first place winner, AllianceChicago, received $10,000 to continue supporting their award-winning clinical innovation program.

Appreciation goes to to Baxter Health, BlueStar Telehealth, and McKesson Medical for their sponsorship.

Check out the other great clinical innovations submitted.

1st PLACE WINNER: AllianceChicago, Chicago, IL

Child Health Engagement and Coaching Using

Patient Centered Innovation (CHEC-UP)

INNOVATION: Artificial intelligence (AI) chatbot technology with human-centered coaching to help families stay current with child immunizations and well visits.

OVERVIEW: HCCN AllianceChicago collaborated with QliqSOFT and Tapestry 360 Health (formerly Heartland Health Centers), to design and pilot AI chatbot technology to optimize messages to families about the importance of regular well child visits and vaccinations.

Using QliqSOFT’s customizable AI chatbot platform, “Quincy”, Tapestry 360 Health created text and/or email dialogue with nearly 250 parents/guardians. “The technology allowed us to optimize our messaging in a way that’s patient-centered,” says Abbey Ekong, Research Manager, AllianceChicago. “It also let us to deliver education in an innovative way that empowers parents/guardians with knowledge before they come to a visit.”

Through Quincy, parents were:

sent reminders to schedule well child visits and immunizations
given evidenced-based child health, immunization, and age-appropriate educational resources before visits
offered easily ways to schedule an appointment online or by phone

Quincy also collected data that was used to continuously improve the parent experience.

OUTCOMES:

8% increase in well child visits and immunizations for the intervention group, compared to the control group
A relative increase of 27% for patients ages 0-17 receiving well child visits and immunizations, following active engagement by parents with the chatbot
88% of parents using the chatbot had a positive experience
100% of participants appreciated the appointment reminders
86% of participants reviewed age-appropriate educational information enjoyed receiving the information

2nd PLACE WINNER: AltaMed Health Services, Los Angeles, CA

Digital Colorectal Cancer Screening (CRC) Outreach and High-Touch Patient Navigation for Abnormal Follow-Up

INNOVATION: A targeted multi-media digital communication campaign followed by high- touch patient navigation to increase CRC screening rates and improve abnormal test follow-up among Latinx patients between the ages of 50 and 75.

OVERVIEW: AltaMed Health Services (AltaMed) designed an innovative end-to-end workflow for CRC screening and outreach. The strategy utilized multiple ways for the health center to directly connect and communicate with patients using email, text messages, and engaging video content. "Because we learned from prior efforts, we were more strategic about this year's FIT mailing," says Evelyn Torres-0zadali, Population Health Manager, AltaMed. "Thanks in part to our participation in the PROMPT Study with Kaiser Center for Health Research, we had a general idea of what it would take to get at least a 30% return rate. We took innovative approaches this year to enhance that."

Initial CRC Screening Strategy:

Mailed 7500 Fecal Immunochemical Test (FIT) kits to high-risk patients
Executed a CRC education campaign using social media, text, and video text messages in English and Spanish. Texts included links to a CRC FIT kit educational video and fotonovela of a woman or man’s CRC screening journey and reminded patients to complete their CRC FIT kit.
Used behavioral theory for messages: if people make a public statement supporting a cause, cognitive dissonance drives their behavior to agree with that statement. For example, AltaMed sent the text, “This is AltaMed, and we want to know what you think! True or False: If I can do something to prevent colon cancer, I will do it.”

Abnormal Test Result Follow-up and Diagnostic Colonoscopy Screening strategy:

A patient navigation team used high-touch strategies with patients who received abnormal FIT results
Navigators made phone calls, patients were sent a frequently asked questions (FAQ) mailer, and texts were sent encouraging patients to get a follow- up diagnostic colonoscopy
Animated colonoscopy and bowel preparation education videos as well as scheduling and appointment reminders were texted to patients
Transportation assistance and financial support were provided when needed

OUTCOMES:

To date, 37.2% of the patients receiving the FIT kits have been screened
Of the patients who received bowel preparation education, only 5% had a “poor” colonoscopy preparation, compared to 33% at baseline
Colonoscopy completion from abnormal result follow-up went from 15% in 2020 to 35% in 2021

3rd PLACE WINNER: Oak Orchard Health, Brockport, NY

Mommy and Me

Healthy We Will Be

INNOVATION: The integration of behavioral health care assessments for postpartum and parenting women (and other caregivers) into child well care visits to identify postpartum depression, anxiety, and other behavioral health issues. Caregivers are then connected with behavioral and social services support, as appropriate.

OVERVIEW: Oak Orchard Health’s Mommy and Me Healthy We Will Be program supports new moms and babies together. The goal is to achieve optimal maternal and child health and normalize conversations around postpartum depression and anxiety. This behavioral health program integrates behavioral health care managers into the pediatric care team. Each care manager attends well child visits from newborns through children five years old.

“Our care managers have become embedded members of our pediatric care teams,” says Robin Govanlu, Director of Behavioral Health, Oak Orchard Health. “Both our pediatricians and families have overwhelmingly positive responses to our care managers' participation in visits. Their presence helps open deeper and more meaningful conversations about behavioral health and resource needs that our patients have not historically had access to during these types of visits.”

Care managers screen moms for depression, anxiety, substance use, and other social determinants of health. They conduct development screenings and track adherence to immunization schedules and well child visits. Assessment results inform referrals to other health center services or external partners. A free diaper bank and an early childhood literacy program are also available.

Mommy and Me Healthy We Will Be is designed to be sustainable and replicable by incorporating several revenue streams, including billable evidenced-based assessments and care models and increasing referrals to other in-service lines.

OUTCOMES:

Since January 2022, 815 caregiver/baby dyads have enrolled in the Mommy and Me Healthy We Will Be program. Hundreds have received behavioral health screenings, and many have been connected with behavioral health, dental, and social services.

726 anxiety screenings
736 depression screenings
744 substance screenings
1,052 social determinants of health screenings
72 patients connected as new family medicine patients
55 referrals to Behavioral health services
84 referrals to Women and Children (WIC)
167 referrals to dental services
5,771 diapers distributed

UPCOMING EVENT

Wednesday, December 14, 2022, 5:00-7:00 p.m. ET

Hosted by NACHC and Theater of War Productions, The Nurse Antigone presents dramatic readings of Sophocles’ Antigone on Zoom—featuring professional actors and frontline health center nurses. What follows is a powerful, guided and interactive discussion about the unique challenges faced by nurses.

The Nurse Antigone aims to generate compassion, awareness, connection, and much-needed healing while celebrating and advocating for nurses at this critical juncture in the history of their profession.