A Healthy Hearts NW clinic describes its remarkable transformation  

by Keli Christman, Clinic Operations Officer at Winding Waters Clinic, OR

I’ve been in health care in Wallowa County for over 26 years, and during my time at Winding Waters, we’ve completely transformed the care we provide.

To give you a better picture of our community, there are about 7,000 people in Wallowa County, with approximately 2.1 people per square mile. We are in the far northeastern corner of Oregon and very frontier, very remote. Many years ago, I was working in assisted living, and I used to dread taking my patients to Winding Waters Clinic! Two physicians took care of the entire patient population: They worked in the emergency room and the hospital — and saw clinic patients. You could sit in the waiting room for hours, waiting for your patient to be seen because her physician was called to the hospital to deliver a baby or see a patient in the Emergency Room.

Heading in a new direction
I joined the staff at Winding Waters in 2006, a short while before we became involved in what would become the biggest influence in our transformation journey, the Safety Net Medical Home Initiative (SNMHI). At that time, we also brought a new physician on-board, Dr. Liz Powers, who would become the leader in our transformation journey. We look for every opportunity to continue improving, and we’re always on the search for the right people to lead projects.

New leadership, combined with the SNMHI collaborative and practice coaching structure, really helped push us in a new direction. We Among many other changes, we implemented open access scheduling, a 24-hour physician advice hotline, and we started the shift to team-based care.

Our dream of true team-based care was realized in 2012 when we were invited by our local critical access hospital to design a new space within their Medical Office Building being built right next to Wallowa Memorial Hospital.

In that time of transition, Wallowa County became a Governor Designated health professional shortage area, one of only two such areas to date in Oregon, and we became an official rural health clinic. Following an intensive application process, we were awarded federally qualified health center (FQHC) status in August 2015. These designations opened so many doors for us — paving the way to partnership and networking with folks across the state struggling with the same things we were.

Whether we’ve compiled measurable data or not, quality has always been at the forefront of what we do. SNHMI set the framework for us to start getting good at quality improvement. It’s been evolving over time, and we’re getting better and better at it.

Our FQHC designation allowed us to officially become a non-profit organization. We’d been a for-profit acting like a non-profit, which I can’t recommend as a business strategy. Now we do more reporting, compile more metrics, and are under more scrutiny — and all of that gives us the opportunity to continually raise the bar. We’re in alignment, and it’s been phenomenal.

Grant funding opened even more doors
Five-plus years ago we partnered with Northeast Oregon Network and Wallowa Valley Center for Wellness (WVCW), our local community mental health agency, to apply for a Health Resources and Services Administration (HRSA)  Small Practice Quality Improvement grant for the integration of behavioral health into our primary care setting. That three-year grant project provided salary support to WVCW to embed three part-time behavioral health coaches into our clinic. One had been a marriage and family counselor, the other two were LPCs. These three individuals participated in a behavioral health certification process, which was a combination of online education and face-to-face training.

The coaches immediately became an integral part of our patient-centered team. One of the coaches remained and became part of our organization after the grant ended. During that project it quickly became second-nature for our physicians to rely on coaches for help with motivational interviewing toward lifestyle changes around weight loss, diabetes, healthy eating or anxiety — with the primary goal of having a positive impact on patient health. The providers have gotten very used to our health coaches sitting next to them in our work pods to the point that when one of our health coaches is on vacation, and we only have one, I hear from them “Where’s our coach, I need her!” Having behavioral health coaches in our clinic is now completely natural to how we function.

Let’s address cost
There’s an important aspect to health coaching I want to address: costs. We have a high Medicare and Medicaid population: almost 40 percent of the county’s population subsists below 200% the federally designated poverty level. Health coaching was initially offered to patients as a free service through the resources in our HRSA grant. After the grant ended, we felt compelled to collect revenue for this service so we instituted a $5.00 fee for each 30-minute visit.

Our uptake just tanked. Our coaches told us, “I’m not very busy. I feel like I’m missing patients, they’re not coming back to see me.” A five-dollar $5 charge was truly a barrier.
So we re-evaluated this and went to our board of directors. Their perspective was: if our providers and clinicians really think this is a valuable service, then let us provide it without charge.

Our board’s support has enabled us to go back to offering behavioral health coaching as a free service. It has been almost a year now, and we’ve seen the tide turn. Coaches are once again busy, and health coaching visit counts continue to grow. Patients have better controlled diabetes and hypertension, and there is a lot of engagement around healthy eating. Our health coaches can connect patients with vouchers to purchase fruits and vegetables at the farmer’s market. We also have a budget for helping patients with temporary housing, transportation, dental care, and prescription drugs.

We look for every opportunity
Our coaches are constantly coming up with new ideas—like let’s do a cooking class, etc. Behavioral health coaching provides services that fall into the ‘soft’ category: We can’t always attach hard data to outcomes, but they make a definite impact on our patients’ lives and their engagement with health care.

In 2015, we enrolled in Healthy Hearts Northwest to help us get a better handle on cardiovascular risk factors.  This project brought coaches into our clinic once again, but this time to work with staff in helping us sharpen our capacity to compile metrics.

Today we have 52 employees, including a full-time data analyst and a quality improvement director. We treat the entire person by integrating behavioral health, oral health, and primary care services. I am exceptionally proud of the care we offer to our community. Winding Waters is going places I would never have dreamed possible.

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Keli Christman is the Operations Officer at Winding Waters Clinic in Wallowa County, Oregon.

Supporting people to quit smoking can have an enormous, lasting impact

By Beth Sommers, MPH, Portland-Metro Practice Enhancement Research Coordinator and Steven Brantley, MPH, Southern Oregon Practice Enhancement Research Coordinator

One of the independent, physician-owned practices I work with in the Portland-metro area has been focusing on identifying patients who use tobacco products and assessing their readiness to quit. Family Medical Group Northeast developed a structured form, called the Tobacco Free Readiness Assessment (TFRA), to gather patient details around tobacco use and patient’s interest in becoming tobacco-free as a means to target cessation conversations and intervention activities based on patients’ self-identified stage of change readiness.

The TFRA gathers information from patients on their perceived barriers and motivations to becoming tobacco-free, gauges their awareness of resources available to help them quit, and asks whether patients are interested in receiving active support in becoming tobacco-free.

After administering the TFRA, dummy codes are used to enter these data into the clinic’s electronic medical record (EMR) so that they could measure their progress. Family Medical Group Northeast created data sets to enable tracking of individual and population changes over time. They became interested in following patients who’ve quit using tobacco so they also assigned a dummy code to the “I have quit” stage. Additionally, they created codes to delineate non-tobacco users and to chart when the TFRA is administered. The TFRA data displays in the clinic’s EMR health maintenance section.

Over six months, Family Medical Group Northeast has fully implemented a Tobacco-Free Readiness Assessment workflow across the practice, and continues with a wide spectrum of other smoking cessation activities. I’m so proud of the progress Family Medical Group East has made in such a short time!
– Beth Sommers

One of the primary care clinics I work with in southern Oregon. Cascades East Family Medicine in Klamath Falls, has taken a slightly different approach with smoking cessation. To get started, clinical champions researched the epidemiology and impact of tobacco use in their population, city, county, and state, and presented their findings to the entire staff. They created a 10-question survey to assess staff interest in quality improvement, retention of tobacco information, and to collect ideas to improve their smoking cessation campaign.

The Cascades East Quality Improvement (QI) team was already screening champions: they were monitoring about 99% of their patients for tobacco use. Their opportunity was to increase their rate of counselling to patients, either via the physician or medical assistant. They worked with their IT department to develop an EMR baseline performance measure and began tracking the percentage of patients that screened positive for tobacco use and that were offered counseling. After 3 months, this counseling metric increased from 12% to 70%.
After another 2 months and a steady increase in counseling offerings, Cascades East dedicated members of the QI team to continue reporting on tobacco cessation activities.

While the team as a whole moved on to other issues as their primary focus, smoking cessation is discussed it at every QI meeting. They’re constantly developing new ideas to address the remainder of their care gap. Smoking cessation is just one piece in the overall structure of our initiative, but supporting people to quit smoking can have an enormous, lasting impact. It’s a privilege to work with a team that’s doing such great work for the people in their communities.
-Steven Brantley

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Beth Sommers, MPH is a Practice Enhancement Research Coordinator at the Oregon Rural Practice-based Research Network (ORPRN).  Her interests include social determinants of health, health policy, primary care transformation, and quality improvement. Beth received her master’s degree in public health from Portland State University, and her bachelor’s degree in physical anthropology from Oregon State University.

Steven Brantley, MPH is also an ORPRN Practice Enhancement Research Coordinator.  His interests include the spatial relationship of health determinants, primary care transformation, and improving access to healthcare. Steven received his master’s degree in public health and his bachelor’s degrees in biochemistry and Spanish from Oregon State University.

Life as a practice coach

by Cullen Conway, MPH

As a Practice Enhancement Research Coordinator with the Oregon Rural Practice-based Research Network (ORPRN), I’m part of Healthy Hearts Northwest (H2N), a national initiative funded by the Agency for Healthcare Research and Quality to help primary care practices improve the cardiovascular care they provide to patients. A core component of the project is the dissemination of the latest evidence-based research via practice facilitators that are coaching clinical teams on improvement projects and better use of their health IT data.

I started my work with clinics in November of 2015. I’m assigned to about 20 practices in the Willamette Valley and on the Oregon coast. I live in Portland, and from there traveled to each of my clinics for an initial in-person visit to get acquainted, go over program basics, talk about their goals, and complete a data assessment. After that first meeting, I visit each clinic monthly. Initially, I alternated between in-person trips and video conference calls, but I realized that the face-to-face meetings were more enjoyable and effective so I’ve begun doing all visits in-person.

Out in the field there’s a wide range of capacity to do quality improvement (QI) work. For most clinics, during the second visit we looked at their data and did early brainstorming on PDSAs (plan-do-study-act cycles.) The PDSAs usually didn’t start until the third visit, but some practices are already in the swing of doing them. For instance, when I returned for the second visit to one of my clinics, they pulled out 3 or 4 PDSAs they’d run since my first visit. They learned from each experiment and created the next from that so this practice was involved from the start in the iterative learning cycles that I think PDSAs are really meant to be.

“A-ha” moments with the clinics are the most gratifying 
One clinic was questioning their aspirin levels and why they weren’t meeting the H2N measure. The numbers they were generating were disappointing them. Together we dug into this, figured out what was happening, and that they were actually doing well. Taking the time to do this gave them the confidence to move towards addressing the blood pressure (BP) measure. Once we’ve been able to help pull data and define the patient population – especially the high risk population – I’ve heard pleased comments about being able to view their patient panel this way, and generating alternative ways of allocating resources.

Frustration around electronic health record (EHR) software is common across clinics. With many EHR products, providers have great difficulty trying to pull data at a population level.

“We want the EHR to get population-level data that we can’t get”
I’ve heard this from providers and practice managers many times: “It’d be much easier for us clinically to just have paper charts”. Providers have invested time and money into new technology for this type of data use, but the systems don’t readily deliver this functionality.

Uncertainty around addressing data theoretically or conceptually can cause anxiety. If a clinic sees it’s performing 55% on the blood pressure measure but can’t see the patient denominator it can be really frustrating. Part of what I do is go into clinics’ EHRs with my teams, create patient reports so they can see the patients who aren’t meeting the measure, and come up with ideas on how to help reach their goal. Pulling data then shifts from a burdensome administrative requirement to information that applies to daily practice — and actually helps patients.

Sharing what works
One of my most effective tools as a facilitator in this project is sharing what’s been working in one practice with another. When I go into a clinic, and ask them where they want to start, they may say “We’re interested in blood pressure” – and I say, “Ok these are a couple of things I’ve seen done” or “I’ve seen a lot of teams focus on outreach”, etc. Sharing those stories is a good way to get the QI wheels turning in peoples’ minds. If people hear that it’s been working in other clinic settings it holds a lot more weight than if it was just me saying, “Let’s try this.” With the other coaches at ORPRN, we support each other by telling these stories to each other – what we’re seeing in our clinics – and so there’s a form of cross-pollination happening on many levels.

Sharing stories is not just about the positive – the things that’ve worked – but the struggles and frustrations that are common across the board. So I find myself often saying “You’re not alone. Let’s see where we can start”. It’s such a powerful message.

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Cullen Conway, MPH is a Practice Enhancement Research Coordinator at the ORPR). His interests include social determinants of health, social justice, and working to reduce health disparities among underserved demographics. Cullen received his master’s degree in Public Health from Columbia University, and his bachelor’s degree in psychology from Lewis and Clark College.

A great self-report tool was key to our success

by Caitlin Dickinson, MPH

I’m a project manager with Healthy Hearts Northwest, based within Portland’s Oregon Rural-based Practice Research Network (ORPRN). Healthy Hearts NW is a national initiative that’s using practice coaching to improve the care given to primary care patients around cardiovascular risk factors. I’d like to share with you what happened when I headed out into the field as a Healthy Hearts NW coach with zero on-the-ground experience.

Great opportunity exists in emerging fields like ours 
Practice coaching is still a wide-open field: no standards exist for the title of practice facilitator. Even these two nouns (coach, facilitator) are sometimes interchangeable, sometimes not. Whether coach or facilitator, working in this capacity isn’t like being a registered nurse, or a licensed massage therapist, or an attorney. There’s no national or state accrediting body, there is no one-size-fits-all definition of a practice coach or facilitator. If you do an internet search for employment as a health care practice coach, you’ll find that many aspects of this profession vary between job postings.

I began working as a project manager at ORPRN in 2015 after earning my Master’s in Public Health and working in OHSU’s OB/GYN department for four years. ORPRN’s mission is to improve the health of rural Oregonians by promoting knowledge transfer between communities and clinicians. Being involved in work that reflects community health values, priorities, and needs with like-minded colleagues is a dream come true for me.

When ORPRN embarked on Healthy Hearts NW, I supervised our team of practice coaches (Practice Enhancement Research Coordinators, or PERCs.) I managed project operations, and my curriculum development perspective served me well in that role. I was intimately involved in the design of the visits and the program. I attended the PERC trainings and had in-depth knowledge of the coaching day-to-day activities.

Staffing changes often necessitate switching roles
Multi-year initiatives like Healthy Hearts NW often undergo staffing changes, and ours was no different. When we lost one of our coaches more than halfway through, Healthy Hearts NW pulled me in as a coach to finish out the project. Because I was thoroughly familiar with the role and the work being done by our coaches themselves, it made sense to step in.

Here’s the thing, though: I’d never actually gone out in the field. I was nervous! Changing gears and becoming a coach meant that I’d inherit clinics that had begun the project with someone else, and were well on their way with their project work.

H2N created a powerful tool in the Quality Improvement Change Assessment, or the QICA. It’s a survey completed by staff and clinicians that assesses their current quality improvement (QI) capabilities and describes aspirational QI capabilities. It is used by the coach to guide them in supporting their practice on their journey to improving patient care. In Healthy Hearts W, our coaches work with their clinics to complete the QICA twice: once at the beginning of their work together, and then again approximately a year later to measure progress.

One of the practices I inherited is a great example of why I love the QICA. The practice took very good care of their patients and had an extremely hard-working team, but they lacked a unified approach for QI – the major focus of Healthy Hearts NW. My colleague had completed the first 10 visits with this clinic. She’d already administered the QICA with the practice at her very first visit with them, and again at the 10th visit. It was at that point that I stepped in, acting as their coach for the last five visits.

Having the QICA to rely on made all the difference
When I started working with the clinic, I had 10 months’ worth of extremely detailed notes and all of this theory swirling around my head, but I needed to zero in on something. I used the QICA, and as a new coach it saved me. I find this really reassuring as a new practice coach! Everyone on the clinic team fills out the QICA, not just the physicians. Although I appreciated having access to the first coach’s documentation, I didn’t have to sort through it all and rely on that. I had a well-rounded self-report from the team I’d be working with to guide my efforts.

I decided to focus in on a priority as determined by the QICA data, versus input from individual providers. The activities the clinic chose to work on with me arose from what they’d been learning from their data. Data began to drive the action, not self-selected provider interests.

This shift had a huge impact on team functioning! The Medical Assistants (MAs) became much more involved in rolling out QI activities. They seemed happier in their jobs and started speaking up in meetings.

My successes as a practice facilitator in the end stages of our project directly result from the solid foundation built by the coaches that came before me, and the timely administration of an effective measurement tool. This team wouldn’t have gotten where they ended up without these two factors. This clinic’s fabulous providers were doing well before Healthy Hearts NW, but they turned an important corner. They now embrace a data-driven, team-based approach to improving the way they run their practice. I feel so fortunate to have witnessed this, and to have been part of their journey.

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Caitlin Dickinson, MPH serves as project manager for ORPRN’s Healthy Hearts Northwest project. Prior to joining ORPRN, she worked for OHSU’s department of OB/GYN and coordinated career development (K12) programs and research projects focused on evidence-based medicine, comparative effectiveness, patient safety, and improving teamwork and leadership among healthcare personnel. Caitlin holds a Bachelor’s degree in biology and chemistry from the University of Denver and a Master of Public Health degree from Oregon State University.

Deepening the practice transformation bench

by Angela Combe, MS

One of the small, single-physician rural clinics I was assigned to in Healthy Hearts Northwest (H2N) stands out in my mind due to the incredible progress made during the time I worked with them. Dr. Emma Boone’s Oregon clinic (a provider pseudonym) was in the process of working towards patient-centered medical home (PCMH) status when they joined H2N. They enrolled in the program with the goal of improving efficiency and processes, as well as learning to maximize their electronic health record software.

Dr. Boone’s practice and its surrounding community have been experiencing steady population growth and need additional providers, but recruiting and training medical professionals has been historically difficult in this region. Dr. Boone’s office was receiving 5-6 new patient calls daily to request care, but she didn’t have the capacity to take on so many new patients. This was another driving reason they sought coaching assistance.

The office manager was extremely engaged
In complete alignment with Dr. Boone, the clinic had a focused and driven practice manager who was invested in the health and type of care delivered in the clinic. I’d say most of the push to improve originated with the office manager, who was trying to forge a path, learn and grow, and implement best practices in the clinic. To ensure everyone was working to the top of their skills and licensure, the two medical assistants (MAs) and the office manager at Dr. Boone’s practice became CMAs (certified medical assistants) during H2N so the clinic had three medical assistants to fill care gaps. They were extraordinarily supportive of one another, and the roles that each played in providing care to their patients.

No prior experience in quality improvement
This group had never done any quality improvement (QI) work prior to H2N, and had very little infrastructure support. Though essentially starting with nothing, they were completely open to change. Of the Pacific Northwest clinics I worked with, I’d say only 25% were motivated to the extent of this clinic. Roughly speaking, 25% are completely disengaged, with the remaining 50% sort of muddling along doing their best.

A big part of coaching in the H2N project was introducing and creating Plan-Do-Study-Act (PDSA) cycles, a classic QI activity. Although our project provided printed instructions, I planned at least one visit for an in-depth discussion about PDSAs with each of my practices. It can take months for a clinic to get the hang of PDSAs – and some never quite understand how to do them, or the value they bring.

Jaw-dropping progress
I’ll never forget the day I showed up at Dr. Boone’s clinic, discussion agenda items in hand, for the first meeting about PDSA cycles. Nothing could have prepared me for what I encountered: the front desk staff had taken on PDSAs with the support of the entire team, and had already completed their first one. They even had results to share, such as what they learned and next action steps. They were so excited to show me what they’d done.

I think my mouth might have dropped open in shock. My plan for that visit was blown! I remember feeling giddy and happy, and celebrating that moment together. Not all days in a coach’s life are like that one, but I hold onto that memory.

Meaningful and exiting to watch this unfold
This is a perfect example of the ways a coach is uniquely qualified to support a practice: by recognizing progress and celebrating success. Their success with PDSAs continued, as the whole team took responsibility for conducting them. There was no single person responsible for QI – they alternated leading each cycle. The team’s enthusiasm kept them going, and it was so meaningful and exciting to watch it unfold. This was a practice that truly transformed.

Such an outcome is the reason I do this work, and seeing success happen before our very eyes is exactly what coaches hope for.  Isn’t this true in so many areas of life, not just health care practice coaching? When working to make changes, it’s great to have someone who really understands to cheer us on. The positive energy just flows, and helps keep us moving towards our goals.

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Angela Combe, MS is a Practice Enhancement Research Coordinator for the Oregon Rural Practice-based Research Network serving the Healthy Hearts NW Eastern Oregon region. She holds a Master of Science in Community Health Education and a Bachelor’s of Science degree in Nutrition/Dietetics, both from the University of New Mexico. Prior to joining ORPRN, Ms. Combe worked as Faculty for the Extension Services of Oregon State University and Washington State University.

Champions of the PDSA

by Denise Weiss, RN and QI Lead at the Rinehart Clinic in Wheeler, OR

In January 2016, I moved to the Oregon coast and joined the staff of the Rinehart Clinic in the northern Oregon seaside town of Wheeler.  One of my roles as an RN is helping with Healthy Hearts Northwest, the program we’ve enrolled in to help provide better cardiovascular care to our patients.

Our clinic’s quality improvement team meets weekly to assess where we’re at with our PDSAs (“plan-do-study-act” cycles”).  You can’t improve unless you know what you’re currently doing, so when we got the Healthy Hearts quality measures (the ABCS), we knew we had to start with blood pressure (BP).  All of the other measures are directly impacted by that.

We made it fun
We did parody skits of what not to do when taking a patient’s blood pressure. For example, in one skit, I wore a heavy-sleeved coat, was drinking coffee, talking rapidly and had my legs crossed.  All the MAs watched and pointed out what was wrong in terms of taking blood pressure.  We laughed a lot while we were learning.

With help from the Healthy Hearts’ materials, we made laminated posters on taking correct BP.  We put them on the walls of each exam room next to the blood pressure monitor so the patients could see.  After we identified some things that were being done incorrectly, we did random skills checking with the MAs.  The clinic supervisor would have each one check off what they were doing.  Putting the laminated sheets in the exam rooms helped get the patients involved.  If an MA was busy and not doing something correctly, the patients might say something like “Oh I have my legs crossed – it says here I’m not supposed to.”  So in this way we involved the patients. They are partners in improving their health outcomes.

Our first PDSA was just getting up to speed
After this, our denominator decreased.   Our next PDSA was on “second reading.”  For those patients not having good BP control (a reading greater than 140 over 90), a second blood pressure was taken at the end of their visit.  Before the MAs wrote the after-visit summary, they would take a second reading.  The theory behind this is that maybe the patient was anxious during the first reading or they just had coffee or a cigarette.  By doing the second reading we could see if the patient was truly hypertensive or if the blood pressure was within range.

After the second-reading BP PDSA, we did chart audits to discover what percentage of our patients were getting that second BP reading. We saw that one team was doing really well with it, but another team was struggling.  We pulled the MAs together to talk about what was and was not going well.  We did another audit two weeks later and saw the same thing.  We then did an incentive, a contest, where the clinic supervisor gave out lanyards.  It was a small, fun motivator! During the process of continued audits, we found an EHR glitch.  Two of the MAs were entering the second reading into one field and the other MA was entering it into another field where it was replacing the first reading.  In this way, we found a documentation piece that was impacting data capture.

Addressing blood pressure alone had a ripple effect
After we started with Healthy Hearts, our blood pressure numbers began to improve.  Then, without having made them a focus, our other numbers started to improve (aspirin therapy and tobacco counselling).

I’m really excited about doing this work.  Our clinic has support from the administration and an overall vision that we are not just focused on our clinic patients, but on the health of our community.  It is all related.  If you improve the health of your community, you improve the health of your patients.

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Denise Weiss, RN is a Registered Nurse at The Rinehart Clinic in Wheeler, OR.  The clinic’s service area is a federally-designated Health Professional Shortage Area, meaning it has an “acute shortage of health care providers,” and also is a federally-designated Medically Underserved Area, which indicates that the area lacks resources “to meet the medical needs of the resident population.” The Rinehart Clinic is working to meet those needs by providing high quality, complete, personalized medical care for residents and visitors.