Written by: Center for Care Innovations

On December 3rd, grantees in the PHASE and TC3 programs had the opportunity to visit one of two health centers that highlighted promising practices and innovative approaches to improve care for patients at risk for cardiovascular disease.

The half-day site visit locations included:


why we picked these sites:

Community Medical Centers (CMC) has seen significant improvements in their blood pressure control rates, even with a large influx of new patients. They have done a lot of work around their culture of improvement and diabetes care, so we wanted to highlight their diabetes group medical visit model and their PDSA boot camp, which teaches staff about improvement methods.

Livingston has also see improvement in their clinical measures. We wanted to highlight some of their key drivers: building a data-driven culture, team-based care, patient-engagement, and leadership support.

Livingston Community Health (Livingston, CA)

Livingston has 6 sites, with a PHASE population of almost 4,000. Visitors to Livingston learned about the aspects of developing and implementing a self-measured blood pressure (SMBP) program. Patient education approaches and materials were shared through an SMBP mock visit. Visitors also observed a clinic flow which highlighted the role of health educators. Livingston also shared their approach to building a data driven culture through data governance aimed at improving data quality, improving data literacy, and maximizing data access.

Our takeaways:

  1. Don’t reinvent the wheel. If great patient-education materials already exist, use them!
  2. Three E’s of Patient-Centered Care: education, empowerment, and engagement.
  3. Focus on wins in a few areas with leadership support first instead of trying to improve in all areas at once.


Download All Resources


Community Medical Centers (Stockton, CA)

Community Medical Centers (CMC) has 20 sites, with a PHASE population size of over 15,000 patients with hypertension, diabetes, and/or ASCVD. Visitors to CMC learned about how a large organization instills a quality mindset and skillset throughout the entire health center. They were able to observe a “PDSA bootcamp”, then deep dove into their diabetes shared medical visit model. The site visit ended by examining other important interventions – such as integrated behavior health – that provide comprehensive care for PHASE patients.

Our takeaways:

  1. Use reporting from population care software or management reports to drive daily action to close care gaps and assess whether improvement efforts are working.
  2. Enable all staff to be improvement leaders by building their skills, and then allowing them to influence improvement at their site.
  3. Try using a pictogram for social needs assessment: CMC found that it was more welcoming to patients, and made it more likely that care team members would fully assess patient needs and make referrals.


Download All Resources

Learning Exchange Debrief Session (Manteca, CA)

After the site visits, participants enjoyed a lunch and learning exchange debrief session at the Chez Shari Conference Center to synthesize what they learned from the site visits and to discuss what they could take back to their own clinic/system.

Thank you to all who participated, and a special thanks to our site visit hosts!



Find this useful or interesting? We’re constantly sharing stuff like this. Sign up to receive our newsletter to stay in the loop.