Tacoma-Pierce County CTG Community Transformation Implementation Plan (Community and Clinical Preventive Services) – May 21, 2012
Community Transformation Implementation Plan (CTIP) – Community Transformation Grant
Community and Clinical Preventive Services – Standardized Quality Measures
Date: May 21, 2012
Site Name
Tacoma-Pierce County, WA
Project Period
By September 29, 2016, increase the number of health care systems implementing common methods of tracking and
Objective (PPO)
treating hypertension and hyperlipidemia from 0 to 5.
Timeframe (PPO) Start Date: 9/30/2011
End Date: 9/29/2016
Objective
This objective includes 3 focus areas: Community Health Workers, use of a common web-based medical record registry
Description (PPO) regarding hypertension and hyperlipidemia and development of quality chronic disease measures across health care
systems in Pierce County. In Pierce County, there are 5 major health care systems: Franciscan Health System, Group
Health, Madigan (military), MultiCare Health Systems and the Puyallup (Indian) Tribal Health Care Authority.
Related Program Community and Clinical Preventive Services
Goal/Strategic
Direction (PPO)
Strategy/Priority Not applicable
Area (PPO)
Annual/MultiBy September 29th, 2013 increase the number of health care systems in Pierce County that use a common set of
Year Objective
standardized chronic disease quality management measures to manage hypertension and hyperlipidemia from 0 to 3.
(AMO)
By September 29th, 2014 increase the number of health care systems in Pierce County that use a common set of
standardized chronic disease quality management measures to manage hypertension and hyperlipidemia from 3-5.
Timeframe
(AMO)
Objective
Description
(AMO)
Start Date: 9/30/2011
Strategy (AMO)
Setting/Sector
(AMO)
Population Focus
(AMO)
Standardized quality measures
Health Care
End Date: 9/29/2014
This objective will focus on instituting and monitoring standardized protocol for tracking and treating chronic diseases
such as hypertension and hyperlipidemia. This protocol will be based on evidence based strategies and informed by
current practice guidelines in Pierce County.
General/Jurisdiction Wide
Estimated Population Reach: 796,000
1
Tacoma-Pierce County CTG Community Transformation Implementation Plan (Community and Clinical Preventive Services) – May 21, 2012
Reach/Number
of Units (AMO)
3 (health care systems)
Milestones/Activities (limit 10)
1. Develop a Chronic Disease
Indicators work group within the
Community and Clinical
Preventive Services Coalition.
Timeline
(InitiationCompletio
n by
Quarter)
Q2-Q3
Activity(ies) Related
to Reducing Health
Disparities*
Short Term
Outcome/
Measure
Lead Staff
Key Partners
Community and
Clinical Preventive
Services Coalition
Members;
Community and
Clinical Services
Coalition Co-Chairs
Community and
Clinical Preventive
Services Coalition
Co-Chairs; Chronic
Disease Indicators
Workgroup Chair
Community and
Clinical Preventive
Services Coalition
Co-Chairs; Chronic
Disease Indicators
Workgroup Chair
Community and
Clinical Preventive
Services Coalition
Members Chronic
Disease Indicators
Chair
Ensure
representation of
targeted
communities
Development of
a work group
CTG Community
and Clinical
Preventive
Services Coalition
Coordinator
CTG Community
and Clinical
Preventive
Services Coalition
Coordinator; CTG
Evaluator
CTG Community
and Clinical
Preventive
Services Coalition
Coordinator
2. Conduct an assessment of
current quality measures systems
at each of the five Pierce County
health care systems.
Q4-Q5
Not applicable
Systems are
identified
3. Conduct a site visit to a minimum
of three health care systems to
become familiar with the quality
measure standards that are
utilized by each.
Q5-Q6
Not applicable
Number and
locations of site
visits
4. Identify chronic disease
indicators to be tracked and
monitored across health systems
within the county.
Q5-Q6
Not applicable
Indicators
identified
CTG Community
and Clinical
Preventive
Services Coalition
Coordinator
2
Tacoma-Pierce County CTG Community Transformation Implementation Plan (Community and Clinical Preventive Services) – May 21, 2012
5. Meet with a minimum of two
administrative leaders per health
system to inform them of and
discuss the health benefits of
utilizing common chronic disease
quality measurements across
health systems.
6. Develop a plan for roll out and
implementation of common
quality measures across all
health care systems in the
county.
Q5-Q7
Research how to
work most effectively
with tribal agencies
prior to meeting with
the Puyallup Health
Authority
Number and
types and
meeting held
CTG Community
and Clinical
Preventive
Services Coalition
Coordinator
Q8-Q9
Not applicable
Plan developed
CTG Community
and Clinical
Preventive
Services Coalition
Coordinator
7. Provide technical assistance to
healthcare leaders on
implementing common chronic
disease measurements.
Q5;
Q6;Q7;Q8;
Q9;Q10;Q
11;Q12;
Not applicable
Technical
assistance
provided
CTG Community
and Clinical
Preventive
Services Coalition
Coordinator
Community and
Clinical Preventive
Services Coalition
Co-Chairs; TacomaPierce County
Health Department
Director
Community and
Clinical Preventive
Services Coalition
Members Chronic
Disease Indicators
Chair
Health care
leaders; CTG
leadership team;
CTG Community
Liaison Specialist
3
Tacoma-Pierce County CTG Community Transformation Implementation Plan (Community and Clinical Preventive Services) – May 21, 2012
Community Transformation Implementation Plan (CTIP) – Community Transformation Grant
Community and Clinical Preventive Services – Health Information Technology
Date: May 21, 2012
Site Name
Tacoma-Pierce County, WA
Project Period
By September 29, 2016, increase the number of health care systems implementing common methods of
Objective (PPO)
tracking and treating hypertension and high cholesterol from 0 to 5.
Timeframe (PPO) Start Date: 9/30/2011
End Date: 9/29/2016
Objective
This objective includes 3 focus areas: Community Health Workers, use of a common web-based medical
Description (PPO) record registry regarding hypertension and hyperlipidemia and development of quality chronic disease
measures across health care systems in Pierce County. In Pierce County, there are 5 major health care
systems: Franciscan Health System, Group Health, Madigan (military), MultiCare Health Systems and the
Puyallup (Indian) Tribal Health Care Authority.
Related Program Community and Clinical Preventive Services
Goal/Strategic
Direction (PPO)
Strategy/Priority Not applicable
Area (PPO)
Annual/MultiBy September 29th, 2013 increase the number of health care systems in Pierce County that utilize a
Year Objective
common web-based medical record registry regarding hypertension and hyperlipidemia from 0 to 3.
(AMO)
By September 29th, 2014 increase the number of health care systems in Pierce County that utilize a
common web-based medical record registry regarding hypertension and hyperlipidemia from 3 to 5.
Timeframe
(AMO)
Objective
Description
(AMO)
Start Date: 9/30/2011
End Date: 9/29/2014
Strategy (AMO)
Setting/Sector
Shared use of patient electronic medical records across health care systems
Health Care
This objective will focus on development and implementation of a common web-based registry of records
that can be accessed by all health care systems in the county. Significant historical and political barriers will
need to be overcome for the five health care systems to trade information on the health information
exchange and establish a joint registry.
4
Tacoma-Pierce County CTG Community Transformation Implementation Plan (Community and Clinical Preventive Services) – May 21, 2012
(AMO)
Population Focus
(AMO)
General/Jurisdiction Wide
Estimated Population Reach: 796,000
Reach/Number
3 (health care systems)
of Units (AMO)
Milestones/Activities (limit 10)
Timeline
(InitiationCompletio
n by
Quarter)
8. Develop a Health Information
Q2-Q3
Technology work group within
the Community and Clinical
Preventive Services Coalition.
Activity(ies) Related
to Reducing Health
Disparities*
Short Term
Outcome/
Measure
Lead Staff
Key Partners
Community and
Clinical Preventive
Services Coalition
Members
Community and
Clinical Preventive
Services Coalition
Co-Chairs
Community and
Clinical Preventive
Services Coalition
Co-Chairs; Health
Information
Technology
Workgroup Chair
Washington State
Department of
Health Technology
Manager
Community and
Clinical Preventive
Services Coalition
Co-Chairs; Health
Ensure
representation of
targeted
communities
Development of
a work group
CTG Community
and Clinical
Preventive
Services Coalition
Coordinator
9. Identify Information Technology
experts/consultants to provide
assistance to the Health
Information Technology work
group as they implement the
shared registry.
Q4-Q5
Not applicable
Experts and
consultants
identified
CTG Community
and Clinical
Preventive
Services Coalition
Coordinator
10. Meet with representatives of the
OneHealthPort system and other
health technology agencies to
understand system
Q5-Q7
Not applicable
Documentation
of meetings held
CTG Community
and Clinical
Preventive
Services Coalition
5
Tacoma-Pierce County CTG Community Transformation Implementation Plan (Community and Clinical Preventive Services) – May 21, 2012
processes/capability, legal
implications, barriers to
implementation, etc.
Coordinator
11. Meet with a minimum of two
administrative leaders per health
system to educate them on the
health benefits of a county wide
patient electronic medical record
registry.
Q5;Q6;Q7
Research how to
work most effectively
with tribal agencies
prior to meeting with
the Puyallup Health
Authority
Number and
types and
meeting held
CTG Community
and Clinical
Preventive
Services Coalition
Coordinator
12. Convene meetings with health
care system leaders to identify
needs and address barriers to
implementation of common
web-based medical record
registry.
Q6-Q9
Not applicable
Documentation
of meetings held
13. Develop a plan for roll out and
implementation of a county wide
electronic medical records
registry regarding hypertension
and hyperlipidemia.
Q8-Q10
Not applicable
Plan developed
CTG Community
and Clinical
Preventive
Services Coalition
Coordinator; CTG
Program
Manager
CTG Community
and Clinical
Preventive
Services Coalition
Coordinator
14. Identify a host for a county wide
registry.
Q11-Q12
Not applicable
Host identified
CTG Community
and Clinical
Preventive
Information
Technology
Workgroup Chair
OneHealthPort
System
Representatives
Community and
Clinical Preventive
Services Coalition
Co-chairs; TacomaPierce County
Health Department
Director of Health
Information
Technology
Workgroup Chair
Community and
Clinical Preventive
Services Coalition
Co-Chairs; Health
care system leaders
Community and
Clinical Preventive
Services Coalition
Members; CTG
Evaluator; Health
Information
Technology
Workgroup Chair
Health Information
Technology
Workgroup Chair
6
Tacoma-Pierce County CTG Community Transformation Implementation Plan (Community and Clinical Preventive Services) – May 21, 2012
Services Coalition
Coordinator
Community and
Clinical Preventive
Services Coalition
Co-Chairs
7
Tacoma-Pierce County CTG Community Transformation Implementation Plan (Community and Clinical Preventive Services) – May 21, 2012
Site Name
Project Period
Objective (PPO)
Timeframe (PPO)
Objective
Description
(PPO)
Related Program
Goal/Strategic
Direction (PPO)
Strategy/Priority
Area (PPO)
Annual/MultiYear Objective
(AMO)
Timeframe
(AMO)
Objective
Description
(AMO)
Strategy (AMO)
Setting/Sector
(AMO)
Population Focus
Community Transformation Implementation Plan (CTIP) – Community Transformation Grant
Community and Clinical Preventive Services – Community Health Workers Community Based
Date: May 21, 2012
Tacoma-Pierce County, WA
By September 29, 2016, increase the number of health care systems implementing common methods of tracking and
treating hypertension and hyperlipidemia from 0 to 5.
Start Date: 9/30/2011
End Date: 9/29/2016
This objective includes 3 focus areas: Community Health Workers, use of a common web-based medical record registry
regarding hypertension and hyperlipidemia and development of quality chronic disease measures across health care
systems in Pierce County. In Pierce County, there are 5 major health care systems: Franciscan Health System, Group
Health, Madigan (military), MultiCare Health Systems and the Puyallup (Indian) Tribal Health Care Authority.
Increased Use of High Impact Quality Clinical and Other Preventive Services
Not applicable
By September 29th, 2015 increase the number of Pierce County health care organizations engaging Community Health
Workers who implement standardized chronic disease quality management measures to manage hypertension and
hyperlipidemia from 0 to 3.
By September 29th, 2016 increase the number of Pierce County health care organizations engaging Community Health
Workers who implement standardized chronic disease quality management measures to manage hypertension and
hyperlipidemia from 3 to 5.
Start Date: 9/30/2015
End Date: 9/29/2016
In Pierce County, there are currently many professionals/paraprofessionals serving in community health worker types of
roles but their approaches and training differ.
The focus of this objective is to increase the engagement of community health workers in the implementation of
standardized quality management measures regarding hypertension and hyperlipidemia.
Increase use of standardized chronic disease quality management measures among community health workers in
community settings
Community
Health Disparity Focus
8
Tacoma-Pierce County CTG Community Transformation Implementation Plan (Community and Clinical Preventive Services) – May 21, 2012
(AMO)
Estimated Population Reach of Health Disparity Focus: 115,701
Priority or targeted populations for this objective include the following subgroups with the highest rates of hypertension
and cholesterol in Pierce County (in ranked order of prevalence): African American, Low Income (less than $20K/yr), and
Native American.
Reach/Number
Not applicable
of Units
(AMO)
Milestones/Activities (limit 10)
Timeline
Activity(ies) Related
Short Term
Lead Staff
Key Partners
(Initiationto Reducing Health
Outcome/
Completio
Disparities*
Measure
n by
Quarter)
15. Conduct a brief assessment of
Q3-Q3
Not applicable
Completion of an CTG Community
Washington State
community professionals and
assessment
and Clinical
Department of
paraprofessionals serving in a
report
Preventive
Health;
community health worker
Services Coalition Comprehensive
capacity (numbers, scope of
Coordinator; CTG Health Education
practice, reach, etc).
Evaluator
Foundation; CTG
Cross Cultural
Collaborative
Coordinator
16. Develop a Community Health
Q3-Q3
Not applicable
Formation of a
CTG Community
Community Health
Worker workgroup within the
Community
and Clinical
Worker Workgroup
Community and Clinical
Health Worker
Preventive
Members; CrossPreventive Services Coalition.
workgroup
Services Coalition Cultural
Coordinator
Collaborative (CCC)
Coalition
Coordinator
Community and
Clinical Preventive
Services Co-Chairs
17. Based on assessment, adopt
Q5-Q8
Not applicable
Standardized
CTG Community
Community and
standards for community health
definition and
and Clinical
Clinical Preventive
workers to include roles,
scope of practice Preventive
Services Co-Chairs;
responsibilities and
developed
Services Coalition Washington State
competencies.
Coordinator; CTG Department of
9
Tacoma-Pierce County CTG Community Transformation Implementation Plan (Community and Clinical Preventive Services) – May 21, 2012
CCC Coalition
Coordinator
18. Hold meetings with
administrative leaders of
community based and health
care institutions to discuss the
health benefits of utilizing CHW
to manage hypertension and
hyperlipidemia.
19. In conjunction with community
partners, identify essential
elements of a community health
worker curriculum to address
hypertension and
hyperlipidemia.
Q6;Q8;Q1
0
Q7-Q10
Prioritize colleges
serving higher
numbers of
individuals in
targeted populations
Number and
types of
meetings held
CTG Community
and Clinical
Preventive
Services Coalition
Coordinator; CTG
Project Manager;
CTG CCC
Coalition
Coordinator
Identify and prioritize
curriculum with a
focus on targeted
populations
Curriculum
developed
CTG Community
and Clinical
Preventive
Services Coalition
Coordinator ;
CTG CCC
Coalition
Coordinator
Curriculum
updated (as
needed)
Health; Centers for
Disease Control
and Prevention
Community Health
Worker Staff;
Community and
Clinical Services
Preventive Services
Coalition Members
Community and
Clinical Preventive
Services Coalition
Members
Community and
Clinical Preventive
Services Co-Chairs;
Tacoma-Pierce
County Health
Department
Director of Health
Community and
Clinical Preventive
Services Co-Chairs
Washington State
Department of
Health; Centers for
Disease Control
and Prevention
Community Health
Worker Staff;
Community and
Clinical Services
Preventive Services
Coalition
10
Tacoma-Pierce County CTG Community Transformation Implementation Plan (Community and Clinical Preventive Services) – May 21, 2012
Members;
Curriculum
Development
Consultant; CTG
Cross Cultural
Collaborative
Coalition
Coordinator
20. Develop work plan for utilizing
community health workers to
manage hypertension and
hyperlipidemia.
Q8-Q10
Ensure placement of
community health
workers in
communities with
the highest chronic
disease burden/need
Completion of a
work plan
System
developed and
adopted
CTG Community
and Clinical
Preventive
Services Coalition
Coordinator; CTG
CCC Coalition
Coordinator
Community and
Clinical Preventive
Services Co-Chairs;
Centers for Disease
Control Community
Health Worker
Staff; Washington
State CTG Clinical
Coordinator; CTG
Evaluator; Division
of Social and
Health Services
Manager;
Community Based
Community Health
Workers; TacomaPierce County
Strengthening
Families
Coordinator;
Comprehensive
Health Education
11
Tacoma-Pierce County CTG Community Transformation Implementation Plan (Community and Clinical Preventive Services) – May 21, 2012
21. Health care systems and/or
community organizations will
formalize shared/joint use of
community health workers for
collaborative benefit to manage
hypertension and
hyperlipidemia.
Q12-Q16
In the Memorandum
of Understanding,
ensure that scope of
practice will prioritize
a focus on targeted
populations
Number of
Memoranda of
Understandings
signed and
received
CTG Community
and Clinical
Preventive
Services Coalition
Coordinator; CTG
Project Manager;
CTG CCC
Coalition
Coordinator
22. Identify funding sources to
support community health
workers such as: Medicaid
reimbursement, local
foundations or health care
systems.
Q8;Q10;Q
12;Q14;Q1
6
Not applicable
Funding
source(s)identifie
d
CTG Community
and Clinical
Preventive
Services Coalition
Coordinator; CTG
CCC Coalition
Coordinator
Foundation
Manager
Community and
Clinical Preventive
Services Co-Chairs;
Community Health
Worker Workgroup
Members; CTG
Grants and
Contracts
Specialist; TacomaPierce County Legal
Counsel
Washington State
Department of
Health CTG
Manager;
Community and
Clinical Preventive
Services Co-Chairs
12