Using Data to Beat Back Disease

During her time with the New York City Health Department, Molly Hart witnessed the way health data can change lives. By analyzing data they collected, she and her colleagues could see health patterns across the city. “Data is what helps build the arguments for policy decisions that affect vulnerable communities.  Access to safe parks and to healthy food, where freeways or factories are built – decisions like these have real effects on health outcomes, and without data, you can’t advocate for change.”

Now, as Healthcare Analytics Strategist at Community Health Center Network (CHCN), Hart sees the power of data in the East Bay.  “We’re working with each of our community health centers to use data to better serve our patients.  We need data to understand our patient needs and where best to utilize limited resources in order to provide the best care.”

Data projects at CHCN range from identifying those in need of preventive care to focusing on specific populations such as those with diabetes or hypertension. In addition, CHCN’s Care Neighborhood initiative identifies patients who are most at risk for hospitalizations and ER usage and helps to prevent those outcomes. “As we prepare to transition to more value based payment systems, it is becoming increasingly important to use data to improve quality, bend the cost curve and keep patients and the center of everything we do.”

PHASE (Preventing Heart Attacks and Strokes Every Day)

With data in hand, patients and their community health centers have the power to beat back disease. When it comes to heart health, CHCN health centers are proving the point with positive results, increasing blood pressure control rates and exceeding targets along the way.  For the past two years, patients who go to CHCN health centers receive more attention to improving their heart health through PHASEPreventing Heart Attacks and Strokes Every Day. As grantees of Kaiser Community Benefit’s PHASE program, the health centers combine a low-cost, easy to use medication regimen and healthy lifestyle interventions for patients with high blood pressure.

 “CHCN health centers have been working to increase blood pressure control rates to 65% from a 61% baseline.  We have actually exceeded that goal and are averaging 67% control rate”

Having diabetes or heart disease means patients are two to four times more likely to suffer a heart attack or stroke.  About 65% of those individuals will die of these events (data from Kaiser Community Benefit).

Upper left: CHCN Chief Medical Officer, Dr. Laura Miller. Right: Molly Hart. Bottom, CHCN Quality Management Manager Xiao Chen and CHCN Quality Management Coordinator Irene Nu

Upper left: CHCN Chief Medical Officer, Dr. Laura Miller. Right: CHCN Healthcare Analytics Strategist Molly Hart. Bottom, CHCN Quality Management Manager Xiao Chen and CHCN Quality Management Coordinator Irene Nu

Data plays an important role at every PHASE stage, from who participates to how provider teams set up and deliver care and monitor patient behavior. With data analytics in hand, participating CHCN clinics aim to produce meaningful improvement in blood pressure management for more than 40,946 patients.

PHASE teams gathered recently to share what works in their health centers:

– Scheduling day-before-appointment calls to increase the likelihood patients will come in and to engage the patient in understanding the importance of the visit

– Using Tableau data reports from CHCN to check how well patients are sticking to their medication

–  Implementing team based care to improve outcomes (where non-provider staff have taken on more responsibilities (using planning reports for huddles to better coordinate outreach and care)

– Incorporating dietician visits

In addition to improvements in blood pressure control and diabetes, participating health centers saw improvements in other determining factors related to lifestyle like tobacco and depression screening, and BMI (body mass index).

CHCN hopes to increase the number of sites participating and to increase the blood pressure control goal to at least 70%, improve outreach and  get everyone curious about the numbers.

– Read more about PHASE.