Mission
The Center for Health Improvement (CHI) seeks to improve the health status of adults and children being served through Montgomery Cares and Care for Kids programs. The CHI works to support quality, efficiency, safety, and patient-centered care within the Community HealthLink delivery care system.

Goals

• Evaluate and improve overall quality, safety, and effectiveness of care through measures of health outcomes and system-wide performance.
• Foster a culture of continuous quality improvement in the provision of care.
• Encourage among CHL clinics an environment of shared learning, collaboration, and best practices in areas of improved access, efficiency, and the delivery of planned care.
• Develop and integrate programs that engage patients in improving their own health and preventing complications of diseases.
• Develop a research infrastructure to attract academic partners and health care leaders to foster innovative approaches that reduce health disparities.

Staff:

Maria Triantis, Vice President, Director, 301.628.3420, Maria_Triantis@primarycarecoalition.org

Maria-Rosa Watson, Research Director, 301.628.3432, Mariarosa_Watson@primarycarecoalition.org

Raquel Samson, Associate Director for Health Improvement, Raquel_Samson@primarycarecoalition.org

Barbara Eldridge, Manager of Quality Improvement, 301.628.3446, Barbara_Eldridge@primarycarecoalition.org

Mary Jane Joseph, Case Manager for Komen Project, 301.628.3458, Maryjane_Joseph@primarycarecoalition.org

Celia Juarez, Patient Navigator, 301.628.3434, Celia_Juarez@primarycarecoalition.org

Michelle Markey, Community-Based Strategy Specialist, 301.628.3435, Michelle_Markey@primarycarecoalition.org

Robin Steinwand-Waite, Consultant, 301.628.3428, Robin_Steinwand@primarycarecoalition.org

Programs/Activities
• Quality and Process Improvement Initiatives
  Evaluation & Monitoring
  Data Integrity
  Quality Improvement Tools
  Quality Improvement Innovations

• Child Obesity Quality Improvement Initiative:  This new initiative will develop a model to align care of overweight and obese Care for Kids (CFK) children with current quality of care standards of the Expert Committee Recommendations on the Assessment, Prevention and Treatment of Child and Adolescent Overweight and Obesity (Pediatrics, Dec 2007), (the ‘Expert Guidelines’).  Care for Kids enrollees who are overweight or obese will receive assessment, referral to appropriate care resources (including the 7331 program, below) and comprehensive care coordination and follow-up, leading to better long-term growth (weight reduction or maintenance) and fewer health consequences associated with obesity.

Included in Child Obesity programs is the 7331 Healthy Families Having Fun program.  This undertaking is a family-centered healthy lifestyle program for low-income overweight and obese children that have been referred by their health provider. Through the five-week culturally relevant program, children and their families learn the importance of healthy food choices and physical activity for long-term health.

• Diabetes Self-Management Education: The Montgomery Cares program supports diabetes self-management education classes at select Community HealthLink clinics. Patient education is designed to enhance a patient’s confidence and ability to manage their chronic condition on a daily basis in collaboration with their health provider.  Clinics offering classes follow a standardized curriculum with approximately eight hours of instruction in basic diabetes care, monitoring, acute and chronic complications, nutrition, physical activity, and psychosocial well-being. The content and length/duration of DSME has been standardized for clinics since the beginning of FY06. 

Classes are offered at various locations throughout the County in English, Spanish, and Mandarin Chinese. Every patient enrolled in DSME takes a standard pre and post-test Diabetes Awareness Survey. Results are posted quarterly for all patients educated.

•  Community-Based Cancer Prevention:   The PCC goal is to provide access to cancer prevention services for 100 percent of low-income, uninsured residentrs in Montgomery County. Through funding from the Susan G. Komen and Prevent Cancer Foundations, the PCC has taken a lead role in developing a Montgomery County strategy to address the unmet breast and colorectal cancer screening needs at the Community Health Link safety-net clinics.

•  Community-Based Research:   The PCC is conducting community-based research, Involving Communities in a Multicultural Network: From Screening to Access to Care. The research is funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH: 1 R21-HL-084001-01), 2006-2008. The purpose of this community-based participatory research (CBPR) project is to develop community-suggested strategies to reduce access barriers to health care among low-income, uninsured populations in Montgomery County, MD, and to test the impact of a community-suggested strategy on access to care. 

• Health Literacy

• Grant Awards
  Jim and Carol Trawick Foundation: Childhood Obesity Initiative
  Gwendolyn and Morris Cafritz Foundation: Childhood Obesity Initiative/7331
  Kaiser Permanente of the Mid-Atlantic States, Healthy Eating Active Living Grant: Childhood Obesity Initiative
• Patient Activation/Self-Management Goal-setting Workshop 
• Committees
  • Quality Health Improvement Committee (QHIC)
  • Subcommittee on Quality Indicators
  • Quality Improvement Collaborative
  • Obesity Prevention Strategy Group
  • Provider Task Force for Childhood Obesity