Health Care Homes Sustainability Roadmap 
Learning

How did participation in the BOLD project impact the professional development of your HCH team members?

The BOLD project encouraged professional development through quality improvement activities that increased providers' knowledge of cognitive screenings and clinical practice changes. Collaborating on the BOLD project with MDH and Stratis Health was mutually beneficial as Genevive is committed to growing provider skills, broadening their knowledge, and taking advantage of learning and quality improvement opportunities. This work was relevant because the Genevive BOLD project team had the flexibility to implement specific strategies based on opportunities identified within our practice through the needs assessment process and alignment with existing Genevive initiatives, enabling us to think beyond our current practice and into the future. 

The team performed an organizational needs assessment to identify opportunities to advance dementia risk reduction, early diagnosis, and caregiver support, educate providers on dementia cognitive screening tools, and address provider workflow barriers to completing screenings. Our needs assessment identified that the community of interest is our primary care patients residing in assisted living and skilled nursing facilities. Based on the need to improve support for people with dementia and their caregivers to enhance their health, well-being, and independence, and educate our providers on sources of reliable information about dementia screening tools, we: 1) Implemented and integrated four cognitive screening templates into our Electronic Health Record (EHR) that is optional but encouraged to use and requires one additional click, 2) and created a provider reference guide to assist with interpreting ten various cognitive screenings, and 3) developed a caregiver support resource tool. 

Do you have any recommendations for other certified HCHs regarding incorporating HCH Learning Collaborative activities?

First, I recommend conducting an organizational evaluation to identify barriers, strengths, and opportunities for improvement to prioritize project strategies before determining which HCH initiative to implement into our practice. Our project initiatives must align with organizational goals, incorporating the Geriatrics 5Ms framework (Mobility, Medications, Mind, Multi-complexity, and Matters Most). We also had to think about our electronic health records system's (EHR) strengths and limitations and how to integrate the cognitive screening tools documentation into provider workflows. Additionally, engaging other team members not part of the BOLD project team was important, as they offered real-world insight.

Furthermore, we provided education on performing cognitive assessments to reduce provider frustration and confusion. The paper format of the tools may be critiqued as incompatible with the EHR, creating a need to scan documents, which is the practice at Genevive before implementation into the provider encounter notes. It's essential to be aware of outdated workflow practices that can be improved by incorporating technology such as your EHR to guide providers, improve efficiency, and provide immediate submission and access to results. 

Finally, beginning with small-scale strategic initiatives is okay; small changes allow us to fine-tune the new processes, demonstrate their impact on practices and outcomes, and set future goals such as analytics and data tracking for the type and frequency of cognitive screenings utilized by our providers. 
Successful implementation requires a multidimensional approach, including culture change and provider-friendly workflow.

Ruby Schoen, DNP, APRN, A-GNP-C, and the Genevive BOLD Grant team

Our road to presenting at Learning Days 2023 began in the spring of 2022, when we transitioned to a new model of care coordination. Through conversations with Population Health and analyzing data to identify opportunities for improved patient outcomes, our team moved towards implementing a more health-driven model.

The dreary, drizzling early spring weather that greeted us on the day of our presentation stood in stark contrast to the bright smiles and excitement our team encountered at Learning Days 2023. After a morning filled with inspirational stories from health care systems across Minnesota, it was time to share our journey!

The nerves that come with public speaking began to creep in as our room quickly filled with fellow health care professionals eager to hear our story. There’s a lot of thoughts that go through one’s mind prior to making a presentation; a storm of “what ifs” peppered with jolts of vulnerability.

The lessons we learned while rolling out a new model of care, and from our subsequent presentation at Learning Days 2023, proved to be invaluable. Perhaps the biggest realization is that we were not alone.

With an entire room packed with like-minded professionals whose questions echoed our own, the atmosphere was filled with energy. We talked with people who were at different stages of their journeys – some who were just beginning to think and plan for changes and new workflows and others who were more seasoned and had pioneered substantial changes long ago. We learned so much while collaborating with others about successes and struggles. Making these connections wouldn't have been possible without Health Care Home Learning Days.

We continue to learn new things to this day. When things don’t work out, we challenge ourselves to reframe our mindset to that of seeking growth and learning from these situations. We are listening to our teams with the same vigor we did at Learning Days. Through open dialogue, we can develop ideas that build upon a strong foundation. Staying consistent with our message, our vision and our plan has benefited our long-term outlook and we've seen great success in our program thus far.

We are looking forward to implementing additional changes in the future to improve our patient’s health outcomes, quality of life and enhance health literacy while reducing cost and improving access to resources.