Population Health Cohort Application

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Population Health Cohort Application

PROVIDER EDUCATION NETWORK
Community-Clinical Linkages
Education and Training
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Population Health Cohort
Practice Management
WellSpot Designation

Applicants must complete all sections of the application in order to be eligible for selection. Completed applications are due no later than October 1, 2023. If you have any questions about the application, please contact Charmaigne.Johnson@la.gov.

Population Health Cohort Goal

The goal of the Population Health Cohort is to improve the health of Louisiana residents through the prevention and management of high cholesterol and hypertension.

Primary objectives:

Increase control among adults with known high blood pressure and high cholesterol
Increase the number of patients identified with previously undiagnosed hypertension
Increase the number of adults with hypertension, and/or high blood cholesterol who are referred to a healthy behavior support service or lifestyle change program

Benefits of participation:

Contribute to Louisiana’s efforts to improve the health of those at risk for cardiovascular disease
Assistance in improving your population health management and quality metrics
Financial incentive of up to $8,875/year
Receive one-on-one support from a Well-Ahead Louisiana Nursing Consultant
Opportunities to learn from colleagues and leaders in cardiovascular disease prevention and management

Step 1 of 8

12%

Organization Information

Facility Name(Required)

Facility Address(Required)

Street Address Parish City State / Province / Region ZIP / Postal Code

Your Name(Required)

First Last

Your Email(Required)

Your Phone(Required)

Your Preferred Contact Method(Required)

Phone

How did you hear about the Population Health Cohort?(Required)

Well-Ahead Louisiana Newsletter

FQHC WellSpots

Louisiana Primary Care Association

Social Media

Other

Check each box to show that you meet all of the selection criteria below.(Required)

Leadership is supportive of participation in the Population Health Cohort

Identification of an internal “Project Lead” who will provide management and coordination to guide the facility through the implementation process and will work with the Practice Coach to implement all aspects of the initiative

Organizational capacity and ability to implement improvement strategies within the facility

Ability to collect data, i.e. (percentage of population diagnosed with hyperlipidemia and hypertension), describe change in practice over time, and participate in QI efforts

How many hours per week do you estimate your facility would be able to dedicate to quality improvement via this project?

Does your organization currently utilize any of the following improvement methodologies? (check all that apply)(Required)

PDSA (Plan, Do, Study, Act)

Lean Approach

SMART Goals (Specific, Measurable, Attainable, Relevant, Time Sensitive)

DMAIC (Define, Measure, Analyze Improve Control)

None of the above

Other

Please specify.(Required)

Please rate your organization’s level of expertise in the following:

Using your EHR to generate registries of patients with hypertension(Required)

1 minimal

5 expert

Using your EHR to determine your overall population's hypertension control(Required)

1 minimal

5 expert

Using your EHR to identify, assess, track and address the referral and utilization of social services and support needs for the impacted patient population.(Required)

1 minimal

5 expert

Using your EHR to determine how many patients with hyperlipidemia have been prescribed a statin therapy(Required)

1 minimal

5 expert

Using your EHR to identify how many adult patients your site serves(Required)

1 minimal

5 expert

Using your EHR to support team-based care(Required)

1 minimal

5 expert

Have an active Community Health Worker (CHW) currently extending care beyond the clinical environment to address social services and support needs(Required)

1 minimal

5 expert

Does your site use any software program that interfaces with your EHR to allow you to view quality measures across your patient population? (hypertension control, average patient wait times, etc.)(Required)

Yes

Does your site have established policies/protocols requiring the use of EHR/HIT and/or standardized clinical measures to track hypertension control measures?(Required)

Yes

Does your site have policies and protocols in place requiring the use of data from EHR/HIT to support team-based care?(Required)

Yes

Data Collection

Does your facility use an electronic medical record system?(Required)

Yes

Which electronic medical record system(s) does your facility use?(Required)

EClinicalWorks

All Scripts

Epic

NextGen

Athena

CPSI

Aprima

Other

Please specify.(Required)

How long have you used your current EHR system?(Required)

Less than 6 months

6 months – 1 year

More than 1 year

N/A

If your facility currently uses an electronic medical record system, are you planning to switch systems anytime within the next 12 months?(Required)

Yes

Unsure

N/A

Facility Information

Which of the following best describes the geographic distribution of your patient population?(Required)

Primarily rural

Primarily urban

Mix of urban and rural

Which range best describes the income level of your current patient population?(Required)

Less than $20K

$20K-40K

$40K-60K

$60K-80K

More than $80K

Total Number of Adult Patients (18-85 years old) in a Year(Required)

Is this an exact number or an estimate?(Required)

Exact Number

Estimate

Is your facility currently working on other initiatives (quality improvement or otherwise)?(Required)

Yes

Describe these initiatives.(Required)

Which of the following services does your facility provide? (check all that apply)(Required)

Primary care

Internal medicine

Urgent/walk-in care

Dietitian

Diabetes prevention program (DPP)

Diabetes self-management support education (DSME)

Other diabetes education

Self-measured blood pressure monitoring program (SMBP)

Case management

Breast and cervical health screenings

Referral to community based organization

Other

Please specify.(Required)

Improvement Project Lead Information

Please select a team member who will serve as the Project Lead for your organization. This person will act as the liaison between your organization and the Well-Ahead Louisiana Nurse Consultant throughout the implementation process. This individual will need to participate in all learning events.

Project Lead Name(Required)

First Last

Professional Credentials(Required)

Job Title(Required)

How long has the Project Lead been employed with your organization?(Required)

Project Lead Email(Required)

Project Lead Phone(Required)

Project Lead Preferred Contact Method(Required)

Phone

Leadership Support

This section should be completed by a representative of your facility’s leadership team.

I agree to support the goals of Well-Ahead Louisiana's Population Health Cohort. Should our application be accepted, I will ensure that necessary resources and support are provided in order to meet all commitments associated with participation in this initiative, including identifying key staff and facilitating their participation in training and capacity-building activities; and providing the team with the necessary guidance, support and encouragement to achieve project objectives.(Required)

I agree.

If you agree to the above conditions, please type your name and title in the space below. This will serve as your e-signature acknowledging acceptance of the above agreement.(Required)

Date of E-signature(Required)

MM slash DD slash YYYY