Healthy Hearts NYC

Seeing the forest and the trees: Balancing ongoing QI and urgent patient needs

by Thomas Gepts, Research Data Associate at NYU School of Medicine

It’s no surprise that homelessness often presents or accompanies a range of health problems. Doctors who see homeless patients must concentrate on urgent and acute issues like substance abuse, malnutrition, mental health issues, and the inability to manage chronic conditions. Even minor, treatable issues may pose an outsized threat because of the barriers to proper care.

Under these circumstances, taking on long-term quality improvement (QI) projects may appear to only stretch doctors further. How, then, can primary care practices strike a balance between the performance boosts offered by QI and the pressing needs of patients?

Sutphin Health Center (SHC), part of Brightpoint Health in New York, is helping answer this question. SHC is a federally qualified health center (FQHC) participating in HealthyHearts NYC (HHNYC), a study funded by the EvidenceNOW initiative of the Agency for Healthcare Research and Quality. Through HHNYC, researchers at NYU School of Medicine are partnering with QI experts at the Community Health Care Association of New York State (CHCANYS) and the NYC Department of Health and Mental Hygiene. Together, they are studying whether external practice facilitators can help small primary care practices improve cardiovascular disease prevention and management.

Incremental, population-level changes can quickly benefit individual patients
SHC has shown that it is possible to reap the benefits of long-term QI efforts while serving a vulnerable and challenging patient population. In 2015, about 70% of the center’s patients were homeless, while 92% lived at or below the poverty line. The center has established relationships with shelters and hospitals, becoming an important component in the care of the city’s homeless.

To rise to the challenge of caring for this patient population, SHC undertakes QI projects like HHNYC and looks for ways to make incremental changes that will immediately benefit patients. Their approach? Empower staff to make suggestions, encourage communication across the center, and find creative uses for existing resources.

Dr. James Ho, a physician at SHC observes, “sometimes [we’ll] see the trees but miss the forest.” In other words, by focusing solely on individual patients, providers can miss opportunities to improve care that come from viewing the bigger picture. But if they understand their patients at a population level, providers can improve the care they provide to individuals.

So SHC focuses on attainable QI goals that could have immediate benefits for their patients. As Debby Garriques, the site’s nurse manager noted, “realizing that this will actually save time” also drives the site’s QI achievements.

Using available resources to help patients quit smoking
SHC’s major effort during the project—a smoking cessation trial—is a perfect example of how this population-level thinking can quickly filter down to individual patients. Led by Garriques, the center surveyed the data and resources available to them. Staff representing different areas of the center and Meital Fried-Almog, their HHNYC practice facilitator from CHCANYS, formed a team.

Using data already in the EMR on patients’ willingness to quit smoking, they aimed to engage “ready-to-quit” patients and offer them the necessary clinical support and treatment. Then they looped in SHC’s medical case manager (MCM), who was already responsible for other patient outreach, to develop a workflow.

“Coming up with a workflow forces us to have the conversation and reiterate the message and see how we can better support the [patient],” says Garriques.

The smoking cessation trial kick-started patients’ efforts to quit and involved their care team in the process. The MCM talked with patients about smoking cessation aids, such as nicotine replacement therapy or prescription drugs, and worked with the doctor to ensure orders were sent to the pharmacy. They also took advantage of external resources by connecting patients with the New York State Quitline. Additionally, the team used staff assessments of a patient’s particular barriers to develop personalized follow-ups to encourage patients to persevere.

How to realize these changes
SHC providers and staff and their HHNYC practice facilitator say open communication and collaboration were central to their success in implementing the smoking cessation trial. Three of SHC’s practices and policies stand out in their success achieving gradual QI changes.

1. Empower staff
Empowering staff to suggest changes and pilot new approaches brings forward new perspectives. Garriques sees the benefit of this office culture: “I’m very comfortable [suggesting changes] … I’m very open with the staff, so if they see something to make it better and smoother, we can try it.”

2. Open communication
Encouraging staff to think proactively about their work and to voice their opinions leads to the second key practice: open communication across different areas of expertise. The smoking cessation trial shows the importance of this ideal: from the EMR experts who compiled the list of patients, to the MCM who conducted outreach, to the providers who ensured patients could receive prescriptions, the SHC team kept communication flowing to effectively design and implement the trial.

3. Making the most of available resources
By bringing forward this broad range of perspectives and abilities, SHC made the most of the resources already available—the MCM, in particular. They also  established a relationship with the New York State Quitline—a readily accessible free resource. “It was just building on things,” Garriques explains, describing how SHC gradually improves by maximizing existing resources and programs.

“Thinking outside of the box is very important,” says Fried-Almog, the HHNYC practice facilitator, summarizing the center’s success. “So is thinking about how you can utilize all your team members. It’s very difficult if you have teams that don’t feel empowered.”

Although vulnerable populations such as the homeless present unique challenges to providers, SHC serves as a welcome example of how modest changes can make a big difference. They designed their approach collaboratively and with an eye for efficient tweaks and fixes—enabling their practice to reap the long-term benefits of QI while meeting the daily imperative of caring for patients with urgent needs. 

See a simplified version of SHC's smoking cessation trial workflow.   

Download the SMART goals worksheet used by CHCANYS practice facilitators during the HHNYC project. It provides a strong foundation to think about incremental quality improvement and it can be modified to meet the needs and target measures of other projects.

Thomas Gepts is a Research Data Associate in the Department of Population Health at NYU School of Medicine, where he serves on studies investigating cardiovascular disease management and diabetes prevention. 

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