Saint Francis Pho Foundation Inc

THE FOUNDATION WAS FORMED TO FOCUS ON IMPROVING THE QUALITY OF CARE DELIVERED TO PATIENTS THROUGH RESEARCH INITIATIVES BASED ON EVIDENCE-BASED PRACTICE GUIDELINES AND THE USE OF INFORMATIONAL TECHNOLOGY TOOLS.

SEE SCHEDULE OTHE IDEAL CARE MODEL-AN INNOVATIVE, PATIENTCENTERED APPROACH TO THE MANAGEMENT OF TYPE 2 DIABETES: TO DESIGN AND IMPLEMENT A QUALITY IMPROVEMENT INTERVENTION TO ADDRESS RACIAL AND ETHNIC DISPARITIES IN KEY MARKERS OF DIABETES MANAGEMENT IN THE SAINT FRANCIS HEALTH CARE PARTNERS ACCOUNTABLE CARE ORGANIZATION. GRANT OBJECTIVES INCLUDE: 1) SUCCESSFUL ENGAGEMENT/ENROLLMENT OF PARTICIPANTS, AS EVIDENCED BY ENROLLMENT RATE OF >50% OF ELIGIBLE POPULATION; SUCCESSFUL COLLECTION OF RACE/ETHNICITY DATA FROM ENROLLED PARTICIPANTS AT RATE OF >90%; INTEGRATION OF EPIC EHR DATA AND AMYSIS CLAIMS DATA; 2) MEANINGFUL IMPROVEMENT IN THE HEALTH STATUS OF PATIENTS - 50% OF PATIENT COMPLETE ALL CDC PREVENTATIVE ACTIVITIES; 80% COMPLETE AT LEAST 1; POSITIVE MOVEMENT TOWARD ADA BENCHMARKS (HBALC, BLOOD PRESSURE, TRIGLYCERIDES, VACCINES); MONITOR EPIC DATA COLLECT; AND 3) ACHIEVEMENT OF PROGRAM OBJECTIVES - ICM CARE COORDINATOR HIRED, AND ENGAGED IN EDUCATION (50% OF ENROLLED PARTICIPANTS WILL COMPLETE ALL 7 EDUCATIONAL MODULES; 90% COMPLETE AT LEAST 1) AND PATIENT CONTACT (75% OF PATIENTS HAVE AT LEAST 3 PHONE CONTACTS). GRANT FUNDING WILL PRIMARILY SUPPORT THE STAFF TIME OF THE CARE COORDINATOR AND REIMBURSEMENT FOR SOCIAL NEEDS RELATED TO TRANSPORTATION AND FOOD INSECURITY.

PROVIDED ONGOING EDUCATION SESSIONS TO OUR PROVIDER NETWORK REGARDING APPROPRIATE HIERARCHICAL CODING, IMPORTANCE OF ANNUAL WELLNESS VISITS AND DEVELOPMENT OF CARE PATHWAYS FOR HIGH RISK PATIENTS.