Ongoing Projects

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Here we’ll share the Population Health updates, and successes, discuss upcoming activities, and more. Thank you for joining us!

Population Health 

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What is Population Health?

Population Health Care Teams

  

 

 

Head back to our blog HERE.

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Here we’ll share the Quality Improvement updates, and successes, discuss upcoming activities, and more. Thank you for joining us!

May Quality Improvement Updates:

 

 

 

 

 

 

 

 

 

April Quality Improvement Updates:

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March Quality Improvement Updates:
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Quality Improvement PDSA’s

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Email Your Ideas: 

QualityImprovement@HealthPoint-TX.com 

Head back to our blog HERE.

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Here we’ll share the Quality Improvement updates, successes, discuss upcoming activities, and more. Thank you for joining us!

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Major Updates:
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Quality Improvement Kickoff

Everyone has completed their QI kickoff. Above all, can we agree Julie has done a great job teaching us how seemingly small changes can make a HUGE impact over time? And how about those shirts for this Texas weather? THANK YOU, Julie!

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From the QI Team:

To be an organization that responds to changing needs of our patients and communities, we must consider how we can continuously improve the quality and safety of care we provide. Thus, improvement begins with “i” means it starts with each of us. 

There are different methodologies and ways of thinking about quality improvement. For instance, one of these is called LEAN. Toyota developed LEAN in the 1950s to maximize production and reduce waste by doing more with less and cutting out anything unnecessary. The LEAN methodology has a unique vocabulary. Such as the word: Kaizen.

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Then, What is Kaizen? 

Kaizen is a Japanese word meaning “continuous improvement.” Kaizen focuses on small changes over time that create extraordinary results. A saying associated with Kaizen is everyone, every day, everywhere. Making small changes every day in our spaces and roles adds to the organization’s total improvement. Moreover, Kaizen is a way of life (the Kaizen Spirit). It is about building new daily habits and improving processes at work and home. 

To summarize, our journey for implementing a quality culture starts with each of you. Creating a quality culture requires that you suggest and implement improvements regularly. Our improvement begins with me, you, each one of us.

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Email Your Ideas: 

QualityImprovement@HealthPoint-TX.com 

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Site Rounding

In September, the Quality Improvement team rounded at all clinic sites to introduce themselves, get to know clinic staff better, and share their approach to quality. Rounding will be part of the Quality Improvement team’s regular activities. During rounds, clinic staff will have the opportunity to make suggestions and bring fresh ideas to the table. Above all, their goal is to make your work easier and improve the patient experience. They need your help! To this end, if you have suggestions, please email them HERE: Quality Improvement Team.

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Current “Plan Do Study Act” (PDSA) Initiatives

The Quality Improvement team is supporting Rockdale as they conduct a “Plan, Do, Study, Act” (PDSA) operation. The goal is to capture patients’ preferred pharmacies. Soon, this valuable information will help clinical staff create more seamless interactions for patients.

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Quality Improvement (QI) Projects

Providers partner with the Quality Improvement team to improve upon HealthPoint’s Uniform Data System statin measure. This measure addresses statin therapy for the prevention and treatment of cardiovascular diseases. These improvement measures will directly impact:

Patients at high risk of cardiovascular events who are 21 years old or older and were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD). They may also apply to patients 21 years old or older who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level greater than or equal to 190 mg/dL. In addition, those previously diagnosed with or who currently have an active diagnosis of familial or pure hypercholesterolemia. Finally, patients 40 – 75 years old diagnosed with diabetes that have a fasting or direct LDL-C level of 70–189 mg/dL are impacted.

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New Ideas

Finally, the Quality Improvement team sparked new ideas and ways of thinking with Caldwell and Somerville clinical teams through fun activities! In one exercise, they worked on the many things you can use a paperclip for. Then, QI challenged staff to think of the worst possible patient experience and how they could create it. Through this activity, clinical staff were creatively reminded of how they can make an excellent patient experience. One of the most powerful reasons for team building is to get results like these. Fun activities that help people see each other in a different light allow them to connect in a new way. Activities between multiple teams build skills like communication, planning, problem-solving, and conflict resolution. Furthermore, they facilitate long-term team building through fostering genuine connections, deeper discussions, and processing. Close-knit teams help ensure productivity and a good work environment.

Head back to our blog HERE.

Nurse Family Partnership® at Texas A&M University 

Learn more about Nurse-Family Partnership® at Texas A&M University’s College of Nursing:

Nurse-Family Partnership® is designed to educate and empower first-time moms. Becoming a mom for the first time can be overwhelming. It is especially difficult for moms and families with limited support. Wouldn’t it be nice to have an expert help you navigate this new territory? More than 340,000 first-time moms just like you have enjoyed the benefits of having a Nurse-Family Partnership® professional¹ at no cost.  We know you’re asking, “is this for real?” It is! Below you’ll find more information about how to enroll and answers to your questions.

Healthy and happy kids come from happy, healthy homes.

Do I qualify?

You must be a first-time mom and 28 weeks or less along. The earlier in your pregnancy you join the program, the longer you and your baby get to realize the benefits!  There is an income eligibility requirement. This program is focused on assisting low-income, first-time moms. Enrollment is 100% voluntary.

Who are they and what do they do?

Your Nurse-Family Partnership® registered nurses are specifically trained for mother-baby care. They support first-time mothers through regularly scheduled in-home visits with moms-to-be. They start visiting your home early in your pregnancy and continue their service through your child’s second birthday.

Dads & Partners Need Help & Support, too!

A new baby can bring lots of changes, especially for first-time moms.  Your nurse can help you and your household prepare for and know how to deal with the changes, challenges and milestones. Their goal is to help you and your family build a healthy, happy home for you and your new baby. To this end, partners, fathers, family members or even your close friends are welcome to participate in your visits. Some visits may simply provide another set of hands to calm a fussy baby or change their diaper. Others may discuss in-depth topics like feeding and sleep schedules to help ensure everyone in your home is taking excellent care of your baby.

You can learn more about Nurse-Family Partnership® at Texas A&M University College of Nursing HERE.

You can learn more about the history and evidence behind Nurse-Family Partnership® , the nationwide program HERE.

Book an appointment with a provider today! 

Complex Care Management

Follow along for our ongoing Complex Care Management project updates.

MOST RECENT UPDATES

Over the next several months, the clinical and population health teams will work with our consulting team.  Health Management Associates was hired to create a program for HealthPoint patients. They will offer additional support to clinical teams, when they see fit.  Health Management Associates will help ensure our patients receive the care that meets their specific health needs. This program will begin at the BCS, Hearne, and Caldwell clinics for now. Then, by the middle of 2022, expansion to other clinics will begin.

Our goal: Create a care management team that will provide further focused care for HealthPoint patients. Specifically those with complex chronic conditions, thus supporting their continued well-being.

• Time of clinic impact: January 2022
• Affected Clinics: Caldwell, Hearne, and BCS will be initial pilot sites. Eventually, HealthPoint plans to expand this program to all clinics.  

What is Complex Care Management?

Above all, Complex Care Management (CCM) effectively assists patients and their caregivers.  It helps to manage medical conditions and co-occurring psychosocial factors. CCM will be deployed to patients with serious medical needs.  Specifically those who often experience a high number of hospitalizations or emergency room visits. The goal of CCM is to improve the patient’s health status and reduce the need for hospital care.

Be sure to check out more content from our friends at the Center for Excellence in Primary Care. 

Return to all projects page. 

Diabetic Retinal Screening

MOST RECENT UPDATE

Since you were here last, we have updates on our Diabetic Retinal Screening Project:

Finally, the wait is over!  By mid-December, the BCS, Madisonville, Caldwell, and Navasota Clinics will receive retinal screening cameras.  Soon, staff will screen diabetic patients for diabetic retinopathy with these newly installed cameras. Before this rollout, Chief Operations Officer, Cas Perez, and the project management team are working with managers to coordinate delivery, installation, and training. Final dates TBD.  STAY TUNED!

Original Project Outline

Our goal: Develop a process for diabetic HealthPoint patients to receive retinal scans to screen for diabetic retinopathy. Screening for diabetic retinopathy is a common practice. In fact, providers can screen patients with a handheld or desktop camera. With this in mind, retinal cameras were purchased and allocated to clinics where patients will soon get screened during their visit.

• Time of clinic impact: December 2021
• Affected Clinics: BCS, Navasota, Madisonville, and Caldwell

Here are a few symptoms to look for from our friends at Mayo Clinic

Symptoms

To begin with, you might not have symptoms in the early stages of diabetic retinopathy. Then, as the condition progresses, you might develop:

• Spots or dark strings floating in your vision (floaters)
• Blurred vision
• Fluctuating vision
• Dark or empty areas in your vision
• Finally, Vision loss

Return to all projects page.

 

Health Information Exchange (HIE)

A Partnership with Greater Houston HealthConnect

In short, our goal was to provide greater continuity of care for our patients who may not exclusively come to HealthPoint clinics.  For this reason, HealthPoint has joined the Greater Houston Healthconnect (GHHC) Health Information Exchange (HIE).  This will allow our organization to access medication records of participating healthcare facilities in their network, like CHI St. Joseph. Of course, the patient must first consented to participate in the program.

Original Goals:

• Time of clinic impact: 9/27/2021 (front desk consent process)
• Affected Clinics: All Sites

MOST RECENT UPDATE: Health Information Exchange

Front Desk Consent

The HIE program through Greater Houston HealthConnect rolled out at the end of September. This project focused on the front-end process of getting patient consent for enrolling in the information exchange, which allows our organization to access the medical records of enrolled patients seen at participating healthcare facilities, like CHI. However, when this program launched, many of our front desk teams ran into problems with eCW logging them out when they attempted to enroll patients. Our Support and Development team has been working to get these issues resolved so we can resume patient enrollment as quickly as possible.

Back to all projects.

TEACH Behavioral Health Partnership

TEACH grant partnership is a game changer increasing mental health care access for the youth of the Brazos Valley. 

MOST RECENT UPDATE:

At the beginning of October, the Behavioral Health team launched a new counseling program. Teams at our ABC and Memorial Clinics have likely already met our student counselors with the Texas A&M Behavioral Health TEACH program. These counselors are available to help both sites offer additional counseling services to patients of any age.  As a result, staff can help facilitate this care with a warm hand-off from any team member. The patients will then have the option to schedule appointments with the student counselors if the counselor sees fit.

Original Article

Texas A&M University Health Sciences Center-Telebehavioral Care has been awarded a $1.6Milion grant by the Health Resources and Services Administration (HRSA) to help expand mental health services for children in the Brazos Valley. This 4-year Behavioral Health Workforce Education and Training Grant represents the beginning of an ongoing partnership.  It allocates trainees to embed at for the most part at ABC and Memorial clinics. In fact HealthPoint will be one of 3 partner organizations with training psychologists in integrated behavioral health care and tele-behavioral care.

Each site will have two part-time psychology trainees available for either a morning or afternoon shift. The psychology trainees will function as informal coordinators in patient triage, including: 

• Treat with brief interventions
• Refer the patient for counseling to a HealthPoint behavioral health provider 
• Consulting directly with the Primary Care Provider (PCP)
• Coordinating with the HealthPoint Behavioral Health Service Coordinator on helping the patient find outside referrals 

If circumstances warrant, the trainee could then see the patient at no cost to the patient or HealthPoint. In addition, through a video call, they could provide consultation to the PCP for any of HealthPoint’s other 12 outlying clinics. Indeed, this is a much-needed service for patients at HealthPoint. “Having worked for 24 years as a practicing pediatric psychologist, I understand the utility of how behavioral health can help children and adolescents. About 50% of problems confronting pediatricians and family practitioners involve behavior, development, and learning. Psychologists are in a great position to be helpful with these kinds of referrals,” said HealthPoint Director of Behavioral Health, William Rae, Ph.D. E

What does TEACH stand for?

Telehealth for the Expansion of Adolescent and Child Healthcare

Who are the TEACH grant mental health trainees?

Meet the four advanced psychology doctoral students who as a result of this grant will be bringing their expertise to provide integrated behavioral health care and consultation to PCPs at HealthPoint. To begin with, they will office out of the Memorial and ABC clinics. Our goal is to eventually expand services to the BCS clinic and other HealthPoint clinics in 2022.

Katie Console is a fifth-year student in the Counseling Doctoral program at Texas A&M University. She grew up in Louisiana and is bilingual in English and Spanish. She hopes to work as a psychologist in an interdisciplinary medical setting one day. Lastly, Katie has two cats and loves to cook.

 

 

Abby Sharer is a fourth-year student in Texas A&M’s Counseling Psychology program. She speaks English and Spanish and hopes to work as a bilingual psychologist after graduation. Finally, Abby enjoys working out, reading, and spending time with her one-eyed cat named Willow. 

 

 

 

Kaylee Jackson is a fourth-year student in the Counseling Psychology program at Texas A&M. She is a native Texan and Aggie football fan. She enjoys cooking, traveling, and watching movies with her partner and three dogs. Also, Kaylee hopes to work in integrated behavioral healthcare settings after graduation. 

 

 

Sherine Presley is a fourth-year School Psychology doctoral student at Texas A&M University. She is a native Floridian who enjoys going to the beach and practicing yoga. Sherine would like to work with children and families within an academic medical center.

 

 

 

Together with the rest HealthPoint Team, please welcome Katie, Abby, Kaylee, and Sherine!

Book an appointment with your PCP to request a referral today!

Check out the report KBTX did on the grant here.