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The Community Health Implementation Plan for Crown Point, focusing on objectives, partners, and timelines for diabetes education and prevention programs. The plan includes evidence-based actions, target dates, resources needed, and anticipated products/results. Objectives range from implementing DPP programs and providing classes for St. Clare patients to increasing the number of insured individuals receiving primary care through HIP 2.0. External partners include FPN, YMCA, ISBH, Wise Woman, CDC, and Indiana State Department of Health.
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Date Created: 5/16/2016 Date Updated:
Goal HP 2020 Alignment: Other Alignment: Comments:
Frequency Short Term: Quarterly
Intermediate Term: Annually
Long Term: Reduction of incident rates of diabetes 3 ‐ 5 years Reduction of complications from diabetes in ED and Inpatient
Indiana Hospital Association
How will we know that we're making a difference?
To decrease incident rates of diabetes and complications from diabetes D‐1, D‐5, D‐ 14 Cardiovascular and Diabetes Initiative, Indiana Healthy Weight Initiative, American Diabetes Association; CDC
Indicator Source Biometric data DPP evaluation/data
Participant data
Improvement in management/behavioral strategies by participants
Pre/Post Test; biometric data
Objective #1: Evidence Base:
Action Target Date
Resources Needed Team
Anticipated Product/Result
External Partners
Implement one DPP program with a target of 10 participants 8/31/
Facility; instructors; marketing
Julie Maller, Chris Mallers, Amy Pleasant, Amy Delaney
Improvement in participant biometric data YMCA
Objective #2: Evidence Base:
Action Target Date
Resources Needed Team
Anticipated Product/Result
External Partners
Provide four classes for St. Clare patients focused on pre‐ diabetes, diabetes management, nutrition, and/or physical activity 12/31/
education for RN
Julie Mallers, Debbie Jordan, Quinessa Bell, Cyndi Maiko
Clinical outcomes trending toward goals as set by ADA and JNC 8
Wise Woman
Develop evaluation protocol 8/31/2016 Evaluation
Julie Mallers, Debbie Jordan, Quinessa Bell, Cyndi Maiko Evaluation
Wise Woman
Market program to patients 12/31/2016 Materials
Julie Mallers, Debbie Jordan, Quinessa Bell, Cyndi Maiko Participants
Wise Woman
Progress Notes
Progress Notes
Implement diabetes education programs for St. Clare patients with low income ADA
ACTION PLAN
Implement the CDC DPP program in the Crown Point Service Area CDC; ISDH
Date Created: 5/18/2016 Date Updated:
Goal: HP 2020 Alignment: Other Alignment: Comments:
Frequency Short Term: quarterly
Intermediate Term: Annually
Long Term: 3 ‐ 5 years
Indicator Source Reduction in hospital readmissions through the Transitions Clinic at St. Clare Health Clinic
Increase the number of insured individuals that have routine preventive services with an established Primary Care Provider.
County Health Rankings
How will we know that we're making a difference?
To increase the number of those who are uninsured able to access primary care AHS‐3; AHS‐ 5
Improvement of individuals with good physical health days Improvement of chronic disease management scores
County Health Rankings
Objective #1: Evidence Base:
Action Target Date
Resources Needed Team
Anticipated Product/Result
External Partners Develop and implement Transitions Clinic 10/31/2016 Epic traing, credentialing of NP's, collaborative physician agreement
Julie Mallers, MaryJo Spearson, Dr. Foriet, Barb Anderson, Dr. MCMorrmick
Transitions clinic will see patients discharged from the hospital unable to get in with their physician within 48 hours.
physician s, ACO
Promote Clinic and services 10/31/2016 Marketing materials
Julie Mallers, MaryJo Spearson, Dr. Foriet, Barb Anderson, Dr. MCMorrmick
Transitions clinic will see patients discharged from the hospital unable to get in with their physician within 48 hours.
physician s, ACO
Develop evaluation system for patients using the clinic 10/31/2016 N/A Julie Mallers, MaryJo Spearson, Dr. Foriet, Barb Anderson, Dr. MCMorrmick
Evaluation data FPN, physician s, ACO
To establish a Transitions Clinic at St. Clare Health Clinic Patient centered medical home model with medical and social services; Joint Commission; AHRQ
Progress Notes In Early phase of credentaling
Objective #2: Evidence Base:
Action Target Date
Resources Needed Team
Anticipated Product/Result
External Partners Accept HIP 2.0 patients at St. Clare Health Clinic with NP's as Primary Panel Providers
credentialing
St. Clare Health Clinic/ FPN
Increase the number of individuals receiving primary care through HIP
Marketing and advertising of expansion 6/1/2016 PR St. Clare Health Clinic/ FPN Develop evaluation strategies 7/1/2016 N/A St. Clare Health Clinic/ FPN
Evaluation Data
Objective #3: Evidence Base:
Action Target Date
Resources Needed Team
Anticipated Product/Result
External Partners Train a Navigator to provide education and resources to patients regarding preventive services, screening, lifestyle modifications, access to healthcare, and social resources.
7/1/2016 ISDH grant for Navigator
St. Clare Case Manager, BCCP, HIP Navigator
Increased utilization of preventive healthcare services
Develop resources for patients, including worksheets, brochures, and other materials
7/1/2016 ISDH grant for Navigator
St. Clare Case Manager, BCCP, HIP Navigator
Patient materials
Develop an evaluation strategy, establish number of potential patients
7/1/2016 ISDH grant for Navigator
St. Clare Case Manager, BCCP, HIP Navigator
Evaluation report
Develop a navigation program to assist patients through preventive healthcare
Progress Notes Fully in progress
Expand services of St. Clare Health Clinic to the underinsured and HIP 2.0 patients Indiana State Department of Health; CHC‐Look Alike Guidance
ACTION PLAN
CMS, AHRQ, Indiana State Department of Health
ACTION PLAN
Progress Notes
Objective #1: Evidence Base:
Action Target Date
Resources Needed Team
Anticipated Product/Result
External Partners Contue to serve patients that are unable to follow up with their physician with in 48 ‐ 72 hours of discharge; increase usage by 10%
12/31/2017 Additional staffing for St. Clare Health Clinic, NP, MA, hospitalist
St. Clare / Case Management/ Nursing / Hospitalist
Reduce readmissions and assist patients with Chronic disease management
Physician s
Progress Notes
To establish a Transitions Clinic at St. Clare Health Clinic Patient centered medical home model with medical and social services; Joint Commission; AHRQ
Objective #3: Evidence Base:
Action Target Date
Resources Needed Team
Anticipated Product/Result
External Partners Continue to Navigate patients through access to healthcare and primary care, social services, and other resources; increase usage by 10%
12/31/2018 ISDH grant for Navigator
St. Clare Case Manager, BCCP, HIP Navigator
Increased utilization of preventive healthcare services
CMS, AHRQ, Indiana State Department of Health
ACTION PLAN
Progress Notes
Develop a navigation program to assist patients through preventive healthcare
Date Created: 5/17/2016 Date Updated:
Goal: HP 2020 Alignment: Other Alignment: Comments:
Frequency Short Term: Post‐program
Intermediate Term: Annually
Long Term: 3 ‐ 5 Years
Objective #1: Evidence Base:
Action Target Date
Resources Needed Team
Anticipated Product/Result
External Partners
Develop marketing materials for participant recruitment 8/31/
Marketing materials
Stepping On team Materials
pharmacies, University of St. Francis, allied health professionals, EMS
Provide training for program staff 8/31/
Training Materials
Stepping On team Trained Staff
pharmacies, University of St. Francis, allied health professionals, EMS
Determine evaluation strategies 8/31/2016 N/A
Stepping On team Evaluation data
pharmacies, University of St. Francis, allied health professionals, EMS
Recruit and provide program to participants into program 12/31/
Training Materials
Stepping On team Participants
pharmacies, University of St. Francis, allied health professionals, EMS
Indicator Source Number of participants in Stepping On program; transfer of learning in program
Program facilitators Pre‐post evaluation program Reduce number of falls in targeted population EPIC Program participant tracking
How will we know that we're making a difference?
To reduce falls and related injuries in older adults IVP‐1.2; IVP 1. CDC
Reduction of unintentional injury in service area Reduction of deaths due to unintential injury in service area Reduction of hospitalizations due to unintentional injury in service area
Indiana Hospital Association data EPIC
Implement the Stepping On program for 420 individuals annually Stepping On, CDC
Progress Notes