A health center serving homeless patients wanted to improve communication with patients. They trained registration staff to collect patient email addresses to allow for a more stable means of contact. Getting patients' email addresses helped the health center prepare for a new patient portal. Staff were retrained on maintaining privacy when emailing patients. This allowed the health center to better communicate with and care for their homeless patients.

1. THE CHALLENGE:
A Health Center serving homeless patients had trouble reaching patients by
phone or postal mail, and wanted to improve their ability to communicate
with their patients.
VIGNETTE #1:
Improving the Ability to Reach
Homeless Patients
WHY IT WAS
IMPORTANT:
Communication with patients
is paramount to providing
quality care. Patients did not
always have a working phone
number, nor did they always
respond to voicemails when
their number was working.
Email addresses, on the
other hand, are free, can be
accessed for free in libraries
and other locations, and allow
for a more stable means
of communication with the
patient while still being HIPAA-
compliant. Getting email
addresses for patients would
also help the Health Center
prepare for the upcoming
introduction of a patient
portal.
WHAT THEY DID:
The Health Center trained
their registration staff to
consistently ask for the
patient’s email address. They
included training to explain
to patients how it helps the
Health Center care for the
patients better. Staff entered
“none” if the patient confirmed
having no email address at the
time, so that it was clear that
the question was asked and
answered.
HOW THEY MADE
IT SIMPLE:
Registration staff had training
and roleplaying, which did not
take a significant amount of
time or change to workflow.
They could measure success
easily as email address was
only one field for patients
who had had an encounter.
Medical staff were retrained on
maintaining HIPPA compliance
via email communication.
Getting Started on the
Quality Journey:
Case Vignettes

2. THE CHALLENGE:
A Health Center which was small and serving many rural patients wanted
to increase the education and self-management of patients with poorly-
controlled hypertension.
VIGNETTE #2:
Improving the Education of Patients
with Hypertension
WHY IT WAS
IMPORTANT:
Patients had challenges
with disease understanding,
medication adherence, and
behavior change.
WHAT THEY DID:
One nurse was designated
as the lead. She used their
EHR to develop a registry of
patients with poorly-controlled
blood pressure, and then met
with them at the end of their
visit. She invited the patient
to a weekly drop-in group,
and also told the patient that
she would be calling them
in the next week to check in
on them. She developed a
weekly early-morning drop-
in group for patients to learn
more about hypertension,
with rotating topics. At
the time of the group, she
would also perform a blood
pressure check. Lastly,
provider time was blocked off
in case patients wanted to
see the doctor for any issue,
which resulted in increased
attendance over time.
HOW THEY MADE
IT SIMPLE:
The nurse talked to the
receptionist and medical
assistants about the project
and their role in making it
successful, for example by
making sure blood pressure
information was recorded
accurately and in the right
place in the EHR, and
making sure patient contact
information was accurate in
the EHR. She was able to
use the EHR to quickly find
patient information, keep
track of touch points, and
track change in blood pressure
data over time. Results
were communicated to the
entire team to share success,
improve practice, and create
energy and enthusiasm for
tackling a new project.
Getting Started on the
Quality Journey:
Case Vignettes

3. THE CHALLENGE:
A Health Center serving LGBT patients wanted to improve the accuracy
and ease of collecting patient-reported information, such as depression
screening responses or questions about alcohol and drug use.
VIGNETTE #3:
Improving the Collection of
Patient-Reported Information
WHY IT WAS
IMPORTANT:
Patient-reported information
is a critical part of the
overall care of patients.
The gathering of such
information can be time-
consuming, and many
health centers struggle to
decide which information
to ask, and with what
frequency. Additionally,
accurate information about
alcohol and drug use and
indications of depression
are important for all patient
populations, but particularly
so for some parts of the
LGBT community.
WHAT THEY DID:
The Health Center applied for
and received grant funding
to use iPads while the patient
is roomed, waiting for the
provider. The responses
entered into the iPad are
immediately transmitted to
the EHR so that the provider
can view the responses during
the visit. Some of the survey
questions also asked about the
patient’s comfort with giving
information via iPad, and
they encouraged addressing
any questions or concerns
with their provider during the
actual visit.
HOW THEY MADE
IT SIMPLE:
The Health Center recognized
that the time that the patient
waits for the provider in the
exam room could be utilized to
gather important information,
without adding significant
time to the MA’s interaction
with the patient. The
implementation team designed
a rotation of questions so
that no patient would be
asked too many questions at
one time. Also, they posited
that some patients might be
inhibited about giving accurate
information about topics such
as drug use when asked in-
person by a staff person, but
would provide more accurate
information via the iPad.
Getting Started on the
Quality Journey:
Case Vignettes

4. THE CHALLENGE:
A Health Center had multiple requirements in the areas of clinical
measurement and improvement, from UDS to public sector initiatives to
commercial value-based contracts. They needed to find a way to focus
the improvement work so that providers and other staff did not feel
overwhelmed.
VIGNETTE #4:
Improving the Prioritization of
Clinical Indicators
WHY IT WAS
IMPORTANT:
The Health Center wanted
to improve patient care
and outcomes, and also
be successful in its value-
based contracts. Although
many of these contracts
had financial incentives,
they were often tied to the
performance of other Health
Centers in their pool, and
the incentives were paid out
6-12 months after the end
of each calendar year. Staff
felt overwhelmed when
faced with expectations of
improving so many different
clinical indicators.
WHAT THEY DID:
The quality staff worked with
the Chief Medical Officer
to have an annual meeting
with the Executive Team,
where results were presented
for each clinical indicator
and a review of contractual
expectations was conducted.
With that information, the
Executive Team then decided
on a very small number of
indicators that would be
prioritized for the coming
year, with introduction of new
indicators on a quarterly basis.
HOW THEY MADE
IT SIMPLE:
With agreement amongst the
Executive Team, the Quality
and Clinical staff had clear
direction and full executive
support, which decreased the
stress felt by staff and help
align resources. Results were
shared through white boards
in the clinical area, and the
quality staff brainstormed with
clinical staff about different
ways that they could improve
the performance. The clinical
teams had ownership over the
work, with the quality staff
available to support them in
different initiatives.
Getting Started on the
Quality Journey:
Case Vignettes

5. THE CHALLENGE:
A Health Center serving a large Latino population had some patients with
uncontrolled diabetes who were not coming into the Health Center for
regular visits, lab tests, or education.
VIGNETTE #5:
Improving the Care of Patients
with Diabetes
WHY IT WAS
IMPORTANT:
Patients with high A1c
values do significantly
better in the long-term with
regular medical visits, lab
tests, and education with
a diabetes educator. It had
been difficult for this Health
Center to identify and reach
out to this segment of their
patient population.
WHAT THEY DID:
The Health Center trained an
MPH intern in the use of its
EHR analytics tool DRVS, a
web-based application that was
easy to use and had EHR data
refreshed nightly. The intern
was able to isolate patients
whose most recent A1c value
was 9 or greater and had not
been seen at the Health Center
in at least six months. The
intern, who was bicultural
and bilingual, was trained by
the diabetes educator in how
to best communicate with
patients about the importance
of visits. The intern reached
out to patients at least three
times telephonically and once
by postal mail. When she
was successful in reaching a
patient, she had access to the
scheduling part of the EHR so
that she could schedule any
necessary appointments or
tests. She also trained the
diabetes educator in the
use of the analytics tool,
so the process could be
sustained after her internship
was completed.
HOW THEY MADE
IT SIMPLE:
The Health Center had the data
available through the analytics
tool, but before this project,
not enough staff were trained
and using it consistently.
This project allowed them to
outreach to patients that were
in need of services but not
accessing them. The use of
a bilingual intern also allowed
the Health Center to design
a project which could be run
by one person, from patient
identification to communication
to booking of appointments.
Getting Started on the
Quality Journey:
Case Vignettes