Collaboration
Winner
SoutheastHEALTH in Missouri implemented strategies and developed partnerships to improve patient care and outcomes related to chronic disease management, readmissions, and social determinants of health issues within their community. Their achievements were made with minimal financial impact to the organization in relation to staffing and other resources while providing improved patient care and outcomes. SoutheastHEALTH’s plan stemmed from a community health needs assessment where information was gleaned from town hall focus group meetings held in the surrounding service region. The assessment was used in the development of their three-year strategic plan, which encompassed readmission reduction and community collaborations. Their initiative has grown from 25 patients to 245 patients.
Runner Up
Mississippi County COVID-19 Vaccination Coalition in Missouri cultivated a partnership between four independent community pharmacies and a county health department who banded together to provide the COVID-19 vaccine, vaccinators and facilities for mass vaccination clinics. As a result of their efforts, this county, which does not have a hospital, had the third highest vaccination rate in southeast Missouri. The Mississippi County COVID-19 Vaccination Coalition is comprised of Beauton Drug, SEMO Pharmacies, Main Street Pharmacy, Simmons and Graham Pharmacy and the Mississippi County Health Department.
Runner Up
The Tidewater Collaborative in Virginia is a multi-hospital collective aimed at reducing high emergency department utilization by their shared patients in southeastern Virginia. Hospital representatives participating in this collaborative built on previous relationships to improve processes for identifying high emergency department utilization patients and increase their use of Care Insights, which are notations about patients’ critical medical/behavioral issues, social determinants and any pertinent care history. Since the program started, emergency department visit rates decreased 14% per month in the region and more than 380 emergency department visits have been avoided.
Health Equity
Winner
Appalachian Agency for Senior Citizens of Virginia launched an innovative medical transportation pilot program to help older adults in this medically underserved region receive consistent care to treat their chronic health conditions. The goal for this program was to increase the availability of medical transportation by 85 percent, however that goal was met and surpassed as transportation availability increased to 98.9%. The requests for rides increased from 8 per month to 227 per month, or a 2,738% increase. As a result, local hospitals saw a reduction in readmission rates that resulted in cost savings of about $9,500 for each readmission.
Runner Up
NOVA ScriptsCentral in Virginia worked to become the go-to resource for unbiased and culturally appropriate information on COVID-19. They collaborated with community members and health care professionals on how to best build vaccine confidence and helped vaccinate 3,000 people. Initially, the bulk of the information shared was available primarily in English, but many of the community members living in northern Virginia that they work with speak a variety of languages such as Spanish, Hindi, Arabic, Chinese, Korean, Amharic and Vietnamese. The culturally diverse staff and volunteers at NOVA ScriptsCentral worked diligently to vet resources from all over the world to make sure the information was correct and available in multiple languages.
Runner Up
C.M. Tucker, Jr. Nursing Care Center in South Carolina implemented an evidence-based education program on compassion fatigue awareness and multiple self-care skill strategies to increase certified nursing assistant retention. Forty-five CNAs participated in the program and after one month, CNA retention increased by 43%. At the end of the fourth month, the facility’s retention rate was 100%. Also, 44% of the full-time supplemental agency CNAs became full-time facility employees, and the use of supplemental agency staff decreased to less than 5% of the total CNA hours worked.
Patient Engagement and Activation
Winner
Bay Aging implemented a robust care coordination program in Virginia to help patients achieve an optimal level of health and well-being while living in their preferred setting. The percentage of participants that completed at least one goal in their care plan was 100%, which is 15 percentage points above the stated baseline goal of 85%. Through this program, Bay Aging achieved accreditation for Case Management for Long-Term Services and Supports through the National Committee for Quality Assurance (NCQA) in September 2021. They met strict standards in areas such as conducting comprehensive assessments, managing care transitions and measuring quality improvement to support people who remain living independently.
Runner Up
Peoples Pharmacy in Virginia bridges gaps within underserved communities and acts as a liaison between patients and clinicians. In particular, they help patients with chronic diseases understand how to manage their care. Their approach begins with training each employee to not only be knowledgeable but to make a positive first impression with patients that builds trust. Staff are instructed to learn more about the cultures of the people they serve, and to avoid making assumptions. This type of engagement results in their patients spending less time under the care of hospitals.
Runner Up
Sentara Halifax Regional Hospital in Virginia leverages an active Patient and Family Advisory Council, which provides a non-clinical perspective that offers guidance and recommendations to meet the needs of the local community. In addition to patient-focused services such as spiritual care, health gardens, a faith story program and a chaplain program, this organization helped organize an Appreciate Service Card initiative that allows patients to acknowledge excellent care and service received during their stay. This increased communication has been a morale booster for both patients and employees.
Population Health
Winner
Sentara RMH Medical Center in Virginia enhanced their diabetes education program when data revealed a significant increase in uncontrolled diabetes and hypertension in their community. This was a result of patients not seeking health care services during the COVID-19 pandemic. The diabetes education program was adapted to reach patients in different settings and from different cultures. The program improved the quality of life, reduced the mortality rate and decreased hospital admissions for their patients. By 2021, their shift from a focus on hospital-based diabetes education to Diabetes Self-Management Education and Support (DSMES) program, held in outpatient primary care settings, has served approximately 900 patients.
Runner Up
Community Health Center of Southeast Kansas focused on innovating and enhancing their hypertension and diabetes program to better serve their underserved populations. As a result, they improved blood pressure control from 79.9% to 81.1% and A1C poor control from 35% to 27.6%. Southeast Kansas has been one of the hardest hit areas in their state and even the United States, in terms of COVID-19 infection rates in 2020 and with the Delta variant in 2021. Despite additional challenges caused by the pandemic, they were one of only two practices in the state of Kansas that achieved Gold Plus Recognition for the Target Blood Pressure Program in 2021.
Runner Up
Neosho Memorial Regional Medical Center in Kansas focused on addressing COVID-19 vaccination hesitancy and increasing vaccination in the community. They established a “Community of Immunity” team to coordinate outreach and education efforts. They held weekly planning meetings and identified barriers, resources and vaccination event needs such as staffing and advertising. They also created interest by offering prizes for vaccinations with a grand prize to be drawn after the second COVID-19 vaccination. By mid-September, 47% of their residents were fully vaccinated and 52% had received their first dose.
Rural Health
Winner
Grande Ronde Hospital and Clinics, an independent hospital predominantly serving Union County in a mountainous area of Oregon with harsh winters, implemented strategies and tactics to improve access to care and support better outcomes for patients and families. Some of these include employing additional pediatricians and psychiatrist and psychiatric nurse practitioners, implementing daily huddles involving the hospital and clinics and transitioning three separate electronic medical record systems to a single system across the care continuum. As a result, this hospital achieved low rates for readmissions of complex and chronic patients, as well as behavioral health patients.
Runner Up
Care Connections Rx provides clinical and consulting pharmacy services, focused on scaling and spreading sustainable team-based care workflows and models to include not only chronic care management, but also Annual Wellness Visits and remote patient monitoring for patients in rural Southwest Virginia. Staff connect with patients each month using remote monitoring technology platforms, which has provided access to care and early diagnosis of potential patient challenges while minimizing staff exposure to infection. As of September, 434 Annual Wellness Visits were conducted, and 112 chronic care management patients have been enrolled.
Runner Up
With the local doctor’s office having been closed for over two years, Family Pharmacy Cumberland recognized an unfulfilled need for low income, elderly members of their rural Virginia community. As many residents have limited transportation to reach a physician’s office, the pharmacy stepped in to provide monthly medication synchronization, deliver medications, administer vaccines and create a Diabetes Care Club to provide free testing supplies and counsel patients on blood pressure and blood sugar results. Over 200 patients in this small rural community, who often turn to the pharmacy with medical, health and insurance questions, are enrolled in the Diabetes Care Club.