Department Of Public Health And Social Services receives $250K…

SMALL HEALTH CARE PROVIDER QUALITY IMPROVEMENT - GUAM COMMUNITY HEALTH CENTERS PROPOSES PROJECT SIGI, A FOUR-YEAR QUALITY IMPROVEMENT INITIATIVE FOCUSED ON IMPROVING HYPERTENSION AND DIABETES CARE FOR ADULTS LIVING IN GUAM. GUAM COMMUNITY HEALTH CENTERS IS THE ISLAND’S ONLY FEDERALLY QUALIFIED HEALTH CENTER AND SERVES A PREDOMINANTLY LOW-INCOME, MEDICALLY UNDERSERVED POPULATION ACROSS TWO CLINIC SITES. MANY PATIENTS FACE BARRIERS RELATED TO TRANSPORTATION, LANGUAGE, COST, LIMITED ACCESS TO SPECIALTY CARE, MISSED APPOINTMENTS, AND DIFFICULTY COMPLETING FOLLOW-UP CARE. THE PROJECT WILL ADDRESS LOW BLOOD PRESSURE CONTROL RATES, HIGH RATES OF POOR DIABETES CONTROL, INCONSISTENT PATIENT FOLLOW-UP, GAPS IN LABORATORY AND REFERRAL TRACKING, AND LIMITED USE OF RELIABLE CLINICAL PERFORMANCE DATA. THE PRIMARY CLINICAL SERVICE FOCUS AREA IS CHRONIC DISEASE MANAGEMENT, WITH EMPHASIS ON HYPERTENSION AND DIABETES. PROJECT SIGI WILL IMPLEMENT STANDARDIZED, EVIDENCE-INFORMED WORKFLOWS FOR BLOOD PRESSURE MEASUREMENT, REPEAT BLOOD PRESSURE CHECKS, DIABETES MONITORING, LABORATORY FOLLOW-UP, MEDICATION MANAGEMENT, REFERRALS, AND PATIENT REENGAGEMENT. THE PROJECT WILL STRENGTHEN OUTREACH TO PATIENTS WHO MISS APPOINTMENTS OR REMAIN OVERDUE FOR CARE AND WILL DOCUMENT OUTREACH ATTEMPTS, BARRIERS, AND OUTCOMES IN A CONSISTENT MANNER. THE PROJECT WILL ALSO IMPROVE USE OF THE ELECTRONIC HEALTH RECORD TO SUPPORT CLINICAL DOCUMENTATION, PATIENT REGISTRIES, OVER DUE-CARE WORKLISTS, DASHBOARDS, AND MONTHLY REVIEW OF QUALITY MEASURES. CLINICAL AND ADMINISTRATIVE STAFF WILL PARTICIPATE IN ONGOING TRAINING, DATA VALIDATION, WORKFLOW TESTING, AND PLAN-DO-STUDY-ACT IMPROVEMENT CYCLES. BILLING AND CODING IMPROVEMENT ACTIVITIES WILL SUPPORT ACCURATE DOCUMENTATION, REDUCE CLAIM DENIALS, STRENGTHEN REVENUE CYCLE PERFORMANCE, AND IMPROVE THE LONG-TERM SUSTAINABILITY OF QUALITY IMPROVEMENT EFFORTS. THE PROJECT WILL SERVE ADULT PATIENTS WITH HYPERTENSION OR DIABETES, WITH PARTICULAR ATTENTION TO MEDICAID BENEFICIARIES, UNINSURED PATIENTS, PATIENTS LIVING AT OR BELOW THE FEDERAL POVERTY LEVEL, RURAL RESIDENTS, PACIFIC ISLANDER COMMUNITIES, AND PATIENTS EXPERIENCING LANGUAGE, TRANSPORTATION, OR OTHER ACCESS BARRIERS. THROUGH COORDINATED CLINICAL, DATA, AND OPERATIONAL IMPROVEMENT, PROJECT SIGI WILL STRENGTHEN CONTINUITY OF CARE, IMPROVE CHRONIC DISEASE OUTCOMES, SUPPORT RELIABLE PERFORMANCE MONITORING, AND BUILD SUSTAINABLE SYSTEMS FOR DELIVERING HIGH-QUALITY PRIMARY CARE THROUGHOUT GUAM.