The Population Health Project Management Office (PMO) team was re-launched in 2020 to bring together leaders across Vanderbilt to address important Pop Health initiatives. Taking a data-driven approach, the team helps VMG address patient care needs and improve performance in value-based programs by designing and implementing new systems, processes and technology.
In 2021, the team has focused on five quality preventive care pillar measures: wellness visits, standard assessments such as fall risk and depression screenings, immunizations, disease management of conditions such as diabetes and high blood pressure, and cancer screenings. The group has worked to increase patient access and develop education programs across adult and pediatric primary care and women’s health clinics, along with Metro Nashville Public Schools and School of Nursing clinics. Clinic team members are equipped with performance dashboards to help identify areas of opportunity for key pillar measures, which also allows for best practice sharing across locations. Clinical champions in each area partner with VMG Quality and Patient Safety Advisors and the PMO to help develop internal training and performance improvement plans.
Throughout the pandemic, the team has been involved in distributing preventive care summary handouts at COVID-19 vaccine sites. These patient materials have included wellness checklists for men, women and children. The PMO has also refined outreach strategies to include new patient engagement channels, such as telehealth and marketing automation.
Several measures are already exceeding performance goals, including adolescent immunization at 69.5% completion rate (57.8% goal), screening for depression and follow-up plan at 77.2% completion rate (70% goal) and annual well woman visits at 67.9% completion rate (64.2% goal). Measure performance goals are set using the 90th percentile HEDIS benchmarks or achieving significant improvement from the previous year’s performance.