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​CCI is partnering with Kaiser Permanente Community Benefit to provide technical assistance on efforts to bring one of KP’s most successful population management programs to communities of the underserved.

Preventing Heart Attacks and Strokes Everyday (PHASE) is a population-based approach to chronic care management that has proven successful at ensuring effective secondary prevention of coronary events. Developed more than a decade ago by Kaiser Permanente, PHASE uses a three-drug regimen and lifestyle changes to tackle cardiovascular disease (CVD). There is very strong evidence that the three-drug regimen—aspirin, ACE-inhibitors, and statins—substantially reduces CVD events in diabetes patients. While CVD remains the leading cause of morbidity and mortality among patients with diabetes, KP has affected a 60% reduction in CVD morbidity and mortality among KP members who were initiated and maintained on the drug regimen.

KP recognized that translating the PHASE program for community settings could have a profound impact on the cost and suffering associated with diabetes. Introducing PHASE to the community would establish a community-wide standard of care and create a common approach to caring for patients at risk for CVD, whether the patient receives care at Kaiser Permanente or a community health center or public hospital/health system.

In 2006, KP’s Northern California Region Community Benefit program designed the PHASE grant initiative which combined: 1) significant financial investments, 2) consultation from Kaiser Permanente leaders who provided the coaching, training, and guidance; and 3) the creation of learning communities for sharing information, problem solving and best practices. The goal of the initiative was to translate this proven strategy to non-Kaiser Permanente community settings. The initiative includes four clinic consortia and four public hospital systems in Northern California encompassing 50+ clinics over eight counties. They are known as “Continuing PHASE grantees”. The organizations include:

  • Redwood Community Health Coalition
  • San Francisco Community Clinic Consortium
  • San Francisco General Hospital
  • San Mateo Medical Center
  • Alameda Health System
  • Community Health Center Network
  • Santa Clara Valley Health and Hospital System
  • The Community Health Partnership of Santa Clara Valley

In 2015, CCI was selected by KP to join a support team charged with identifying technical assistance needs, aligning resources, and facilitating a community of practice implementing PHASE. We are working in tandem with the Center for Community Health and Evaluation and the Center for Excellence in Primary Care to:

  • Improve data collection, reporting and analysis to support panel management and quality improvement;
  • Increase provider buy in to the PHASE medication regimen;
  • Support multi-disciplinary care management teams dedicated to providing health coaching, lifestyle support and addressing medication adherence;
  • Increase clinics’ ability to make workflow changes necessary for population health management.

CCI is brining its expertise building vibrant learning communities, leveraging experts and sparking innovative thinking practices to the PHASE community in Northern California.

In 2016, CCI was selected to lead Technical Assistance for a PHASE collaborative in the Central Valley. The five grantees are focusing on data-driven decision making and building capacity in that area. The collaborative will involve coaching, three in-person learning events, and other online learning opportunities.

Key Resources

Access the Continuing PHASE resource site

Access the Central Valley/Fresno cohort resource site

PHASE Medication Protocol (“PHASE on a Page”), click here.

PHASE Building Blocks, click here.

For more, click “See All Related Resources” to the left.

Timeline - “Continuing PHASE”

June 17, 2015 — Wireside Chat with Dr. Marc Jaffe

Webinar recording of discussion with Northern California lead clinical expert, Dr. Marc Jaffe held on Wednesday, June 17, 2015. Dr. Jaffe answered questions from participants on PHASE medication protocol. To view the recording, click here.

July 13, 2015 — In-Person Convening

This convening was held for the Continuing PHASE grantees. It provided grantees with an understanding of the initiative, reporting requirements and resources.

September 2, 2015 — Clinic Assessment Webinar

This webinar provided an overview of the PHASE evaluation and the assessment tool domains and describe how assessments can be practically applied for planning and development of training programs. To view the webinar, click here.

October 7, 2015 — Clinical Data Webinar

This webinar reviewed PHASE data and guidelines. To view, click here.

October 13, 2015 — Motivating Change Workshop

This workshop was offered to the Continuing PHASE grantees, as well as the clinics they support.This workshop is one of many trainings offered to grantees.

November 2, 2015 — Motivating Change Workshop

This workshop was offered to the Continuing PHASE grantees, as well as the clinics they support. This workshop is one of many trainings offered to grantees.

January 25, 2016 — In-Person Meeting

This meeting was held for the Continuing PHASE grantees.

April 20, 2016 — Wireside Chat with Dr. Marc Jaffe

In this webinar, Dr. Marc Jaffe reviews the American College of Cardiology and the American Heart Association’s 2013 Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. The guideline no longer advises LDL control targets as the optimal way to reduce cardiac risk. Rather, statin intensity is endorsed. To view the webinar, click here.

June 14, 2016 — In-Person Meeting

This meeting is for Continuing PHASE grantees.

October 6, 2016 — Wireside Chat with Dr. Joseph Young

This webinar is presented by Dr. Joseph Young, Hypertension Clinical Lead for Kaiser Permanente Northern California. The webinar, presented as part of the PHASE program, details KP Northern California’s key elements of a comprehensive hypertension control program, KP’s hypertension treatment algorithm, key takeaways from various studies, and case examples. The webinar concluded with a Q&A session with Dr. Young. To view the webinar, click here.

October 26, 2016 — Wireside Chat with Dr. Lisa Gilliam

This webinar will be presented by Dr. Lisa Gilliam, Endocrinologist at Kaiser Permanente Northern California. The webinar, presented aas part of the PHASE program, will be about A1c Control.

November 16, 2016 — Final In-Person Meeting

Participants of the PHASE program will gather for a final time this year in person.

Timeline - Central Valley/Fresno Cohort

February 24, 2016 — Kickoff Webinar

This webinar kicked off the Central Valley/Fresno cohort of the PHASE program. To view the webinar, click here.

March 30, 2016 — PHASE Assessment, Reporting Metrics, Workbooks Webinar

The webinar reviewed the preliminary results of the PHASE Assessment for the cohort organizations, introduced the PHASE reporting metrics, and explained the project workbook that grantees will be using. To view the webinar, click here.

April 26, 2016 — In-Person Meeting

Cohort organizations gathered in Merced, CA to learn about data-driven decision making.

May 18, 2016 — Data Governance Webinar

This webinar, presented by Health Catalyst, discusses the staff roles that participate in data governance, established a foundational understanding of the triple aim of data governance and explore how to get started. To view the webinar, click here.

June 22, 2016 — Case Studies in Data Governance Webinar

This webinar took another look at the topic of data governance. We heard from three partners, who shared their journey through data governance:- Amy Ham, Chief Data Officer, CommuniCare Health Centers
- Dana Valley, Associate Director of Quality Management, West County Health Centers
- Kai Nissley, Chief Operations Officer, Santa Rosa Community Health Centers

To view the webinar, click here.

July 20, 2016 — In-Person Meeting

This meeting gathered the cohort organizations together to dive deeper into data-driven decision making.

August 31, 2016 — Trouble with Data Quality? We’ve Got a Checklist for That! Webinar

This webinar focused on the HITEQ Center’s Data Quality Checklist, part of a comprehensive guide that includes using data for improvement. Dr. Jerry Osheroff of TMIT Consulting, LLC discussed the main components of the checklist and data validity, where data is:
  • verifiable
  • accurate/reliable
  • retrievable
  • complete

We also heard from the health centers participating in our PHASE Central Valley/Fresno program about how far along they are in their journey to producing performance data that everyone trusts. Finally, we heard from Jillian Maccini, project manager with the HITEQ Center, about the HIT/QI Guide, which provides guidance and tools for conducting HIT/QI projects.

To view the webinar, click here.

September 27, 2016 — Tools You Can Use: Making the Most of i2iTracks to Ensure Data Quality Webinar

This webinar is presented by Nancy Thompson, VP Education & Training at i2i Population Health. The webinar was presented on September 27, 2016 for participants of the PHASE Central Valley/Fresno program, funded by Kaiser Permanente Northern California.The goals of the webinar are to:- Understand some data basics
- Discover the steps to data stewardship success
- Learn how to validate clinical measures & review tools to help you (using a PHASE measure example)
- Identify tactics for an ongoing and effective data quality strategy

To view the webinar, click here.

December 1, 2016 — Final In-Person Meeting

This will be the final in-person meeting of the year and current grant cycle.