Strengthening the Capacity of Safety Net Partners in Using a Population Health Approach
Over the past decade, the PHASE program has evolved in response to changes in the healthcare environment and increased capabilities among our partners. Today’s PHASE program is based on Kaiser Permanente clinical expertise and years of the on-the-ground feedback from our partners. We are always finding new ways to improve the program, tell the story of our collective journey, and understand the broader impact of this program has on our communities. This goals statement is designed to provide greater clarity to all audiences, using a consistent voice.
Thank you for being a part of PHASE 2017-2019. We look forward to improving patient care for all people, working side-by-side with you.
Prevent heart attacks and strokes in high-risk patient populations served by the community health care safety net.
We aspire to eliminate preventable Cardiovascular Disease from our communities so that all people in our communities have controlled blood pressure, controlled Hemoglobin A1C levels and are tobacco-free.
Kaiser Permanente Northern California aims to support PHASE grantees in being nationally recognized for their excellence in providing cardiovascular disease preventative care, as measured by their performance against nationally established benchmarks. All participating community health centers, and public hospital and health systems, are:
Effective deployment of the protocol’s cardioprotective medication bundles (e.g.PHASE on a Page) will be reflected in significant health improvements among the general patient population and patients with diabetes. Milestones measurements will be based on national standards, specifically HEDIS measures for blood pressure control, and Hemoglobin a1c control.
Initial improvement efforts will focus on supporting grantees to achieve or maintain the 75th percentile in one or both HTN-related HEDIS measures.
In addition to initiative-wide goals, partners will focus performance improvement efforts based on other PHASE-related priorities identified in their Charter for Improvement. Coaches will work with individual organizations to refine and address these goals/targets.
Still have questions about what this means for you? Read the PHASE Goals FAQs.
PHASE Initiative-Wide Goals: Updated for the Second Half of the 2017 – 2019 Grant Cycle
Kaiser Permanente Northern California is investing in community health centers, consortia and public hospital and health systems in order to prevent heart attacks and strokes in patients served by the health care safety net. Significant progress has been made to enhance care processes supporting hypertension control in the first half of the PHASE grant cycle. Yet every grantee still has substantial opportunity to prevent additional heart attacks and strokes by bringing more patients with uncontrolled hypertension under control. All grantees are asked to continue their efforts to re-engineer care processes to improve their HTN control as indicated by two key metrics: BP Control in HTN Patients and BP control in DM Patients.
For the remaining 18 months of the current PHASE initiative, organizations are expected to express an achievable improvement goal that gets them closer to national benchmarks for excellence across all their sites, with the following considerations:
When assessing organizational capacity and improvement priorities, some grantees will determine they have the ability to address additional PHASE targets. In this circumstance, these organizations are encouraged to identify these targets and goals in the Charter for Improvement.