Community Health Centers of Florida-Davies Community Health Organization Award

Using a comprehensive EHR-enabled quality improvement strategy focused on adherence to best practice protocols and heavy technology-enabled patient engagement strategies has sustained excellent care coordination while maintaining a high level of care delivery that scores well above national benchmarks. Community Health Centers of Florida's, a federally qualfied community health center serving 57,000 uninsured, underinsured, and Medicaid patients in central Florida, use of technology to conduct pre-visit planning and drive self-management of chronic conditions has almost doubled the percentage of patients with a diagnosis of hypertension who have a blood pressure under 140/90 within their patient population. CHC of Florida further advances continuity of care by linking primary care and dental care within the EHR, which prevents potential risks associated with dental surgery for patients with morbidities. CHC also has developed an innovative change management strategy that reviews patient data to ensure that the organization is constantly evaluating care outcomes and adjusting workflows to insure continuous learning and improvement. As result of these efforts, CHC of Florida has received a Level III Patient Centered Medical Home designation from NCQA. 

Clinical Value

In order to best provide and improve the quality, safety and efficiency of care within the organization, CHC turned their focus to the Patient Centered Medical Home (PCMH) model. The CHC Quality team then embarked on a journey to implement PCMH programs to support patient care planning, patient care coordination, chronic disease management and patient engagement.  This case study outlines how CHC of Florida utilized EHR-enabled workflows to support the care continuity necessary for a patient centered medical home to improve population health and care outcomes.

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Return on Investment

The inability to exchange patient information among providers, track patient results as well as medication intake made providing services to over 56,000 patients a year challenging. Implementing an EHRsolved issues with real time access to clinical and financial data and improved overall functionality at the point-of-care. Today, CHC is one of only a handful of FQHCs in the nation to have an integrated medical and dental EHR, be accredited by the Accreditation Association for Ambulatory Healthcare, as well as having 52 providers successfully attest to Meaningful Use Stage I. This case study highlights a step-by-step process throughout the implementation process and by advancing the clinical information system platform through executive support, resulting in significant return on investment.

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Change Management, Workflow Analysis, and Improvement

As often occurs with rapid geographic growth, coordination and standardization of clinical processes and support across stand alone facilities is challenging.  With a focus on enhancing the patient experience and staff satisfaction, the CHC Informatics team embarked on a corporate initiative to standardize and streamline workflow and navigation within the EHR.  This was done by leveraging workflow analysis and the reengineering of core workflow processes. Included in the project were focal points on establishing an ongoing support network and internal controls, using methodology to help support, monitor and maintain workflow practices.

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Patient Safety Enhancement

 Management of patient medications is an integral aspect of a comprehensive electronic health record (EHR).  Ensuring this function operates seamlessly for both the provider and patient is an important element of the patient visit. E-prescribing can be a challenge to implement. Nonetheless, CHC was determined to provide the technology to its pharmacy and provider groups. The goal was to improve patient safety and quality of care by providing care givers with visibility into real-time patient information to help manage prescribing needs and habits, the implementation of alert and warning systems at the point of prescribing and eliminating prescription errors due to ineligible writing and verbal miscommunication. CHC wanted to ensure all aspects of e-prescribing occurred without being cumbersome for the providers and that pharmacy staff was included as a part of the patient centered health home initiatives, offering both convenience and affordability for the patients. 

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Keywords: 
Community Health Centers, quality, Dental, patient engagement, Change Management