TC3 Support Portal: About the Program

Program History & Overview

In 2003, Kaiser Permanente initiated a program called ALL (Aspirin, Lisinopril, and a Lipid-lowering medication protocol) to reduce cardiovascular disease (CVD) for patients with diabetes and/or coronary artery disease. The effectiveness of the program led several Kaiser Permanente Regional Community Benefit offices to support the translation of this program to local safety net providers, including the Preventing Heart Attacks and Stroke Everyday (PHASE) program in Northern California.

This latest cycle of this initiative will engage technical assistance and evaluation partners as the Support and Learning Team. The Support and Learning Team will provide a structured approach to technical assistance to meet the needs of grantees and clinic sites with varying levels of capacity and experience implementing population health management programs.

Grantee Deliverables: In advance of each in-person learning session we’ll share a template for your team to complete a storyboard that outlines the progress of your project. These storyboards will be shared at the learning sessions as a way to provide updates on your progress to your co-TC3 teams, as well as solicit feedback. Your team will present a final end-of-project storyboard at the last in-person session.

Download Roadmap

The refreshed approach looks to build off of a decade of work in the safety net. While many tenets will remain the same, there are a few changes from the last cycle, which include:

• Channel robust programmatic support resources to high need areas: We will partner with an organization to act as project office and build a Support and Learning Team that will be charged with developing and deploying a robust set of implementation supports, including technical assistance, training and coaching. We will also refine our focus from five large geographic areas that are disproportionately affected by CVD risk, to three of the most affected: Los Angeles, San Bernardino and Riverside Counties. These counties have cities with higher percentages of people with high blood pressure and coronary heart disease as well as less healthy community conditions overall.
• Lift up population health management strategies in the safety net: The technical assistance and training support will help participants reinforce the skills necessary to effectively targetinterventions and use data to drive outcomes. These skills help create the conditions necessary to successfully adopt and implement the CVD intervention. Past programs provided limited support in this area, and the revamped program will include more robust resources.
• New focus on strengthening organizational capacity: Successful population health strategies are best sustained when an organization is strong. New resources will be provided to the grantees to assess the capacity of their own organization, to identify needs and develop a tailored plan to address unique needs. Organizational capacity can include strengthening financial stability, strengthening panel management or creating more robust care teams. Grantees will be provided resources to assist their development to achieve their goals in addressing CVD care and overall organizational capacity. The Support and Learning team will work with grantees to identify at least one area of organizational capacity to target and strengthen.
• Reinforce local safety net relationships: This refreshed approach will provide resources to grantees to support reinforcing geographical relationships for organizations serving high-need patients. Joint learning opportunities will help local entities collaborate and share best practices to overcome local obstacles.

In addition, the Support and Learning Team will work to assist grantees with data reporting, validation, and visualization by:

• Assessing readiness and capacity for population health management;
• Providing ongoing coaching and training;
• Hosting local and statewide forums to share and spread best practices; and,
• Navigating and customizing training opportunities to match grantee needs.

This initiative has four key goals:

1. Increase the adoption and implementation of population health management strategies that decrease CVD risks for safety net patients, including implementation of an evidence-based medication protocol. There will be explicit support to advance the adoption of the medication protocol, but there will also be a recognition that successful implementation requires optimizing clinical conditions to sustain a culture of improvement.
2. Strengthen the capabilities of safety net organizations to adopt relevant elements of Dr. Tom Bodenheimer’s building blocks of high-performing primary care.1 These elements will not only optimize the clinical environment for population health but also have the potential to improve the overall health of the participating clinics.
3. Improve grantees’ ability to report and use data to drive performance at multiple levels – clinic sites, health center organizations, and the consortia and public hospital systems (PHS).
4. Improve the capacity of consortia and public hospitals to support population health management among their clinic networks.