In 2019, Upper Peninsula Health Care Solutions, Inc. was awarded the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Small Health Care Provider Quality Improvement Grant (SHCP – QI) for a third, three-year project period.
With these funds UPHCS working with two care-delivery partners (Gibson Family Health Clinic in Newberry, MI and Schoolcraft Rural Health Clinic in Manistique, MI) to enact the UPlift program. The UPlift project is integrating behavioral health services into these primary care clinics using the evidence-based Collaborative Care Model (CoCM) of behavioral health integration. Primary activities include:
- Establishing behavioral health care teams at each participating clinic
- Developing clinical workflows (using Lean tools and methodology) to accommodate CoCM
- Workforce development through online training and Extension for Community Health Outcomes (ECHO) case-based learning opportunities
- Continuous quality improvement through the periodic measurement of patient health outcomes and feedback from both providers and patients
The UPlift program is designed based on evidence indicating that integrating behavioral health with primary care improves health outcomes in general, and especially for those patients with comorbid chronic disease and behavioral health diagnoses. This program will proceed through 2021 and will serve as a template for integrating behavioral health into primary care offices throughout the region.
In 2016, the grant funded a 3 year project to implement an evidence-based quality improvement model that tested the efficacy of systemic changes on a specific set of quality metrics, using health information technology to track and report on quality and cost. The goal was to promote the development of an evidence-based culture and encourage the delivery of care that benefits from coordination among medical team members and provider entities in the primary care setting. Specific objectives centered on enhanced chronic disease management, with a focus on diabetes and cardiovascular disease.
2016-2019 Project Objectives:
- Improve diabetes and cardiovascular disease chronic care management practices by promoting the development of an evidence-based culture and delivery of coordinated care in the primary care setting
- Support utilization of Certified Electronic Health Technology (CEHRT) for real-time chronic disease population identification: detailed reporting; clinical decision support; patient outreach; patient portal education and utilization, and tracking and reporting of population specific data
- Support clinic participation in quality initiatives such as Patient Centered Medical Home (PCMH), CMS Quality Payment Program, and Healthcare Effectiveness Data and Information Sets (HEDIS)
The project served 40+ participating clinic sites throughout the Upper Peninsula.