Promising Practices: Clinical, Quality

Methodology: This practice enables a health center to develop and implement recognized diabetes prevention (National DPP) and self-management (DSMES) programs to improve patient outcomes, reduce costs, and build capacity by focusing on accreditation/recognition, core components, and a strategic business plan.

To replicate this practice, an organization should focus on adhering to recognition standards and structuring a comprehensive business case for program development and implementation:

1. Identify the Problem and Need (Problem Statement).
◦ Present the prevalence of diabetes nationally, at the state level, and within the health center's patient population.
◦ Discuss the health and financial consequences of diabetes, referencing that the estimated cost of diagnosed diabetes in the U.S. is $412.9 billion, with medical expenditures 2.6 times higher for people with diabetes.
◦ Discuss the gaps in current care for diabetic patients, addressing factors like limited program availability, lack of provider awareness for referrals, limited staffing (diabetes educators), and challenges with insurance coverage and billing.

2. Establish Program Design and Strategy.
◦ Determine eligibility for each program using blood test results (e.g., HbA1C) for risk identification (prediabetes 5.7%–6.4%; diabetes ≥6.5% ).
◦ Identify a strategy for implementing the key components of the National DPP (e.g., managing weight loss of 5–7% and increasing physical activity) and DSMES (e.g., promoting healthy eating, being active, and healthy coping).
◦ Engage key partners, including local pharmacies, health plans, hospitals, and community groups, for effective partnerships.
◦ Incorporate complementary services like Medical Nutrition Therapy (MNT) into the programs, as studies indicate MNT combined with National DPP or DSMES improves outcomes.

3. Adhere to Recognition and Accreditation Standards.
◦ Ensure the program has the capacity to deliver the intervention over at least one year and uses a CDC-approved curriculum for National DPP recognition.
◦ For National DPP, require participants to meet weekly for the first 6 months and biweekly for the last 6 months, and adhere to the CDC requirement that at least 35% of participants are diagnosed via blood testing (or GDM history).
◦ For DSMES, adhere to the six National Standards, including Standards 4 (Delivery and Design) and 6 (Measuring and Demonstrating Outcomes).

4. Develop Implementation and Evaluation Plans.
◦ Determine Key Performance Indicators (KPIs) to measure and evaluate the program's impact, tracking metrics such as: A1C, BMI, LDL-cholesterol levels, and blood pressure (Clinical Outcomes).
◦ Discuss the expected cost savings, showcasing the net monetary benefit (likely to save money) and the Quality-Adjusted Life Years (QALYs) gained.
◦ Establish staffing, roles, and training plans for leadership and staff, and develop a marketing strategy.
◦ Ensure the organization has the necessary infrastructure to quantify intervention costs, measure changes in cost of care, and track patient referrals, data analysis, and billing capability.

Methodology: This practice enables health organizations to use an operational framework to successfully integrate Community Health Workers (CHWs) into HIV care teams, leading to measurable improvements in patient access, adherence to Antiretroviral Therapy (ART), and viral suppression rates.

To replicate this practice, an organization should follow these steps:
1. Establish the CHW Program Structure. Implement an Operational Framework that provides step-by-step guidance covering CHW recruitment, standardized training, and ongoing supervision. Address barriers to integration, such as unclear CHW roles or lack of standardized training.
2. Identify Priority Patients. Identify clients for intensive CHW intervention by reviewing program rosters, surveillance data (to obtain lists of clients who have had a viral load test in the past six months), and clinic testing data (to find newly diagnosed individuals who have never linked to care). Priority patients should include those who are not virally suppressed, have a new HIV diagnosis, have a history of missing or late appointments, or have unstable housing.
3. Conduct Regular Patient Encounters. Implement weekly client check-ins to measure progress, check medication compliance, and provide appointment reminders. Document each patient encounter as a separate note on the Electronic Health Record (EHR) to ensure better collaboration with the rest of the care team.
4. Provide Targeted Education and Counseling. Conduct regular education sessions with patients on subjects like HIV transmission, ARV medication basics, chronic disease-HIV connections, patient safety, and wellness.
5. Coordinate Services and Partnerships. Assist patients by helping them adhere to ARV treatment, explaining health benefits, and coordinating referrals for social or behavioral needs. Strengthen partnerships with HUD and local agencies to improve patient safety and coordinate services.

Methodology: This practice implements the comprehensive Mental Health First Aid training for CHWs, positioning them as trusted community members uniquely able to provide immediate and meaningful support by identifying distress signals and intervening before a mental health crisis escalates, particularly among populations at greater risk for issues.

To replicate this practice, organizations must provide the specialized MHFA training to their CHWs to ensure they can execute real-time responses and reinforce support networks:
1. Provide Comprehensive Training: Offer CHWs comprehensive Mental Health First Aid training (either Youth or Adult MHFA) led by a certified instructor.
2. Recognize and Identify Crisis Signs: Ensure CHWs are equipped to identify warning signs of mental health distress, which might otherwise go unnoticed, to intervene quickly. Common indicators include difficulty with daily tasks, extreme mood swings, withdrawal, or increased aggression.
3. Provide Immediate Support and Reassurance: Empower CHWs to act quickly to offer comfort and initial support to individuals experiencing crisis or non-crisis situations.
4. Connect Individuals to Resources: CHWs must connect those in need to professional care and accessible resources, such as referring them to trained counselors via the 988 Suicide & Crisis Lifeline.
5. Apply Real-Time Skills: CHWs utilize hands-on skills learned through training to respond effectively, strengthening the individual’s support network and reducing the risk of severe mental health outcomes.

Methodology: This practice provides health centers with a systematic process and tools for recruiting, hiring, and integrating licensed Dental Therapists (DTs) into the care team, ensuring compliance with a state's scope of practice, supervision, and documentation requirements, thereby filling oral health workforce gaps and increasing access for communities with additional needs. It uses standardized documents such as a sample job description, request for privileges, and a template for the Written Practice Agreement (WPA).

To replicate this practice, health centers should implement the following steps:
1. Prepare Policy and Review State Requirements: Review the state's Dental Therapy scope of practice and supervision model. Review and check for needed Policy & Procedure Manual changes, specifically regarding dental program policies, the organizational chart, and the unique supervision/authorization process required for DTs.
2. Develop Recruitment Documents and Compensation: Prepare a clear, articulated job description (using the sample provided in the manual) and a DT privileging form (using the sample provided). Develop a competitive wage and compensation package, which may include a sign-on bonus, moving expenses, or a service term agreement if recruiting from another state.
3. Ensure Operational and Clinical Readiness: Ensure the health center has the appropriate space (typically 1-2 chairs), instruments, staff (typically 1-2 assistants), and overall capacity to support the DT. Ensure a sufficient patient base and procedure mix to maintain a full schedule for the DT.
4. Recruit, Onboard, and Educate Staff: Utilize support from organizations for distributing job postings. After interviewing and hiring, introduce the DT to the entire staff, allowing time for questions and answers, and ensure the DT feels welcomed and accepted by the team. Prepare all dental staff and providers by educating them on the DT role, their scope of practice, and how workflows may change.
5. Establish the Written Practice Agreement (WPA) and Supervision: Complete the credentialing process (e.g., CHAMPS enrollment, Medicaid Health Plans) and have the DT complete the privileging form. The supervising dentist must collaborate with the DT to draft the Written Practice Agreement (WPA), which must be signed by both parties and is valid for three years. The WPA must include details on:
◦ The services, procedures, practice settings, and limitations authorized for the DT.
◦ A quality assurance plan for monitoring care, including patient record review, referral follow-up, and chart review.
◦ Protocols for managing medical emergencies and administering/dispensing medications.
6. Provide Mentorship and Communication: Appoint a committed mentor for the DT and encourage daily huddles. Ensure the DT always has a means to communicate with their supervising dentist as needed during care provision. The supervising dentist must be available on a regularly scheduled basis for consultation and review of records.

Methodology: This practice enables healthcare providers to effectively implement a team-based Patient-Centered Medical Home (PCMH) diabetes care management program. The strategy involves using team-based care, patient registries, and risk stratification to align interventions and improve clinical outcomes.

To replicate this practice, an organization should follow these eleven steps for starting a diabetes care management program:
1. Identify a Population Health Tool: Identify a population health tool or an electronic medical record system to generate a panel of individuals with diabetes.
2. Identify a Risk Stratification Process: Define a process to identify risk levels (low, medium/rising, and high) for the diabetes patient panel. Risk stratification should categorize patients based on claims data, chronic conditions, utilization, adherence to treatment plans, and mental health status.
3. Define the Care Team: Define the care team, which may include a Primary Care Provider, Care Manager, Pharmacist, Diabetes Educator, Registered Dietitian Nutritionist, Community Health Worker (CHW), Endocrinologist, and Mental Health professional.
4. Determine Care Team Processes: Determine the care team’s processes and interface, utilizing team-based strategies such as providing structured care according to evidence-based clinical guidelines and engaging in goal setting with patients.
5. Identify Partners: Identify specialists and community partners to refer patients.
6. Determine KPIs and Measurement Processes: Determine Key Performance Indicators (KPIs) and processes for measuring the program, including assessment based on structure, process, and outcome measures (such as HEDIS or UDS measures).
7. Communicate Launch Plan: Communicate the launch plan to staff and patients.
8. Begin Enrolling Patients: Begin enrolling patients into the care management program and conduct outreach to the panel based on the risk level care team process.
◦ High-Risk Patients: Require the most intense intervention and need frequent care management outreach (e.g., once a month). These patients may have HbA1c >9% or multiple risk factors.
◦ Rising/Medium-Risk Patients: The model of care focuses on managing risk factors; care management reduces progression to high risk and overall costs. Outreach should occur every 6–8 weeks.
◦ Low-Risk Patients: The care model aims to keep the patient engaged and can be managed remotely, requiring outreach every three months.
9. Complete Assessments and Care Planning: Complete assessments and care planning in accordance with guidance from NCQA and ADA, and organizational policies.
10. Discharge Patients: Discharge patients from the care management program once goals are met or the patient disengages.
11. Evaluate the Program: Evaluate the program at the frequency and based on previously identified KPIs and measurement processes.

Methodology: This practice enables healthcare providers to effectively implement a team-based PCMH diabetes care management program by standardizing the care management process (Assessment, Plan of Care, Treatment/Monitoring, and Evaluation) and ensuring compliance with NCQA Electronic Medical Record (EMR) documentation requirements.

To replicate this practice, an organization should utilize the care management process, which is circular and ongoing:

1. Screening and Assessment
◦ Screen patients to determine their need and risk level for care management services, gathering key information on past health conditions, utilization of services, polypharmacy, and non-medical health needs.
◦ Complete a comprehensive assessment that identifies the patient’s physical, emotional, socio-economic status, service utilization, and educational needs.
◦ Conduct a diabetes-specific assessment that covers concerns such as the initial diagnosis date, history of diabetes-related ER visits or hospitalizations, blood sugar monitoring frequency, food difficulty, physical activity habits, and medication adherence.

2. Plan of Care Development
◦ Develop the Plan of Care in agreement with the patient and the care manager, ensuring it includes Specific, Measurable, Achievable, Relevant, and Time-Bound (SMART) goals.
◦ Establish both self-management goals (focusing on the patient's role) and care management goals (identifying holistic goals).
◦ Ensure the EMR documentation supports NCQA requirements, including incorporating both goal types and providing the patient/caregiver a written copy of the care plan.

3. Treatment, Monitoring, and Care Coordination
◦ Organize and execute continuous care coordination activities by collaborating with the care team and payors.
◦ Identify care gaps (e.g., HbA1c, retinal eye exam) and provide assistance with referrals to specialists, such as Diabetes Self-Management Education and Support (DSMES), Medical Nutrition Therapy (MNT), and podiatry.
◦ Implement referral tracking procedures to ensure referrals are met, including overseeing authorizations, retrieving results/notes, and updating the EMR.
◦ Monitor elements like progress toward established goals, medication use and adherence, appointment compliance, and ER and inpatient utilization.

4. Evaluation and EMR Integration
◦ Review and evaluate the patient’s interventions and goals, clinical outcomes, utilization, and access to care on an ongoing basis.
◦ Utilize the EMR as a foundational element of the PCMH program to create data repositories for performance measurement, organize care around interprofessional teams, and effectively track referrals and labs.
◦ Ensure the EMR allows for timely notification of results and flagging abnormal results for clinicians.
◦ Review the patient's status with the care team and close the case once the care management goals are met.

Methodology: This practice guides health centers in developing a comprehensive workforce development strategy focused on creating and clearly communicating career paths, thereby reducing high rates of burnout and turnover (nearly half of mental health workers consider leaving due to workforce shortages) by offering consistent opportunities for professional growth and advancement.

To replicate this practice, health centers should implement the following steps:
1. Integrate Career Pathways into the Comprehensive Workforce Plan: Identify career paths as a key area of the retention strategy within the overall Comprehensive Workforce Plan. Recognize that staff are more likely to stay with the organization if professional growth and advancement opportunities are available and accessible.
2. Determine and Disclose Career Paths: Define and disclose specific skills- and competency-based career paths to employees. Structure these paths to include typical growth stages for mental health providers, such as progression from Student/Resident to Non-Licensed Independent Practitioner (LIP) Provider, to LIP, and potentially to Clinical Supervisor, Admin Supervisor, or a Broader Agency Role.
3. Define Skill Requirements and Training Resources: Determine the necessary skills and competencies required to achieve various roles or career stages within the health center. Identify professional development, continuing education, and mentorship resources available for staff to gain those required skills.
4. Implement Targeted Skill-Building Strategies: Utilize various skill-building methods, including Upskilling (developing deeper expertise in a current role), Cross-Skilling (gaining skills in a lateral role), and Reskilling (training for a completely new role), to invest in the professional growth of employees.
5. Communicate and Evaluate Development Plans: Clearly and consistently communicate career path information and resources to all employees. Invest in career ladders that train employees for the successful achievement of leadership positions, and plan for a Formal Development Plan Evaluation to track progress.
6. Support Retention with Organizational Benefits: Supplement career pathways with other vital retention strategies, such as offering increased compensation, support for continuing education and student loan repayment, flexible/variable work schedules, and operating as a wellness-focused organization. Ensure the Mental Health Department receives the same level of support as other clinical departments.

Methodology: This practice utilizes a multi-step implementation framework derived from the COMMIT group (Child Obesity Management Models in Teams) to establish an Intensive Health Behavior Lifestyle Treatment (IHBLT) program for children with obesity within a primary care setting, focusing on long-term wellness rather than solely weight loss.

To replicate this practice, a health center should follow these steps:

1. Assess Capacity and Partnerships (Step 1)
◦ Identify and recruit motivated staff for the FHWP team, including Nutrition Leaders and Exercise Leaders, along with billable providers (medical providers, Registered Dietitians, or behavioral health providers).
◦ Designate a Project Champion to advocate for the program and a Project Manager/Coordinator to handle logistics, training, and follow-up.
◦ Establish partnerships with Community-Based Organizations (CBOs), such as YMCAs, churches, or recreation centers, to potentially share space, equipment, or staff assistance.

2. Select Curriculum and Determine Billing (Steps 2 & 3)
◦ Select an evidence-based FHWP/IHBLT curriculum (like MEND, chosen by the COMMIT group) that meets the American Academy of Pediatrics' recommendation of at least 26 contact hours.
◦ Adapt the curriculum to ensure cultural competency, including utilizing familiar language, relevant food examples, and actively avoiding language that promotes weight stigma.
◦ Research reimbursement opportunities and involve billing and coding experts early to build billable services (such as group visits or individual assessments by RDs or providers) into the FHWP for sustainability.

3. Configure Logistics and Workflow (Steps 4 & 5)
◦ Plan space by reserving safe locations, which may include dedicated group rooms, staff lounges, waiting rooms (after hours), or shared CBO space.
◦ Work with the IT team to establish a data infrastructure to capture necessary measures in the Electronic Medical Record (EMR) and create standardized documentation templates.
◦ Create a consistent workflow for each session, including pre-launch checklists, supply gathering, team huddles before class, and brief team debriefs afterward for continuous Quality Improvement.

4. Recruit Participants and Ensure Retention (Step 6)
◦ Recruit families with children diagnosed with obesity, overweight conditions, or Type 2 Diabetes.
◦ Employ varied recruitment methods, such as EMR referrals, word-of-mouth promotion by providers, social media advertising, and sending personalized letters.
◦ Focus on FUN, flexibility, and support to aid retention, including offering reminders (calls/texts), providing incentives (gift cards, cooking supplies), and being accommodating regarding missed classes.

5. Evaluate and Reflect (Step 7)
◦ Define success with patients and families, focusing on long-term benefits such as improved confidence, physical fitness (e.g., exercise recovery heart rate metrics), and mental health, rather than just weight loss.
◦ Track key clinical metrics, including changes in BMI z-scores, blood pressure, A1C, and lipids.
◦ Conduct regular team reflection, including short debriefs after each class, to review fidelity, discuss challenging dynamics, and identify Quality Improvement (QI) opportunities.

Methodology: This practice provides enrollment specialists with five defined actions to overcome barriers that prevent domestic violence (DV) survivors from obtaining critical health insurance and healthcare access. The strategy emphasizes staff education, client awareness, and formalizing partnerships with local DV programs.

To replicate this practice, health centers should focus on training and implementing the following five core actions within their enrollment and outreach teams:
1. Know Special Enrollment Periods (SEPs): Ensure enrollment specialists know that survivors of DV and their dependents may purchase health insurance at any time during the year by requesting a Special Enrollment Period (SEP) through the Call Center.
2. Understand Financial Supports: Train staff to help legally married survivors who do not live with their spouse and file taxes separately to qualify for financial help based solely on their own income, making health insurance more affordable.
3. Build Local DV Partnerships: Direct enrollment specialists to build formal bridges with local DV programs (via state, territory, or tribal coalitions) to collaborate on increasing health insurance enrollment, providing staff medical coverage, or offering supportive services onsite for clients.
4. Increase Survivor Awareness: Ensure staff proactively educate clients about their eligibility for the SEP and related financial provisions using an adaptable script, such as informing clients they may be eligible for coverage at any time and financial support not tied to an abuser.
5. Increase Team Knowledge: Work as a team (including clinic staff and enrollment specialists) to support survivors and their dependents in getting enrolled, regardless of whether they are staff or patients, recognizing that all survivors may need help with coverage for long-term health consequences of abuse.

Methodology: This practice implements a comprehensive, person-centered model, based in a safety net community health center, to establish continuity of care and housing stability for formerly incarcerated individuals, particularly those with HIV, given that linkage to housing is vital for viral load suppression and decreased recidivism.

To replicate this practice, health centers should implement integrated care planning and utilize peer staff across the pre- and post-release phases:

1. Start Discharge Planning Early: Begin programming and comprehensive discharge planning 60 to 90 days before an individual’s release from incarceration.
◦ Use this time to secure necessary paperwork, including medical records and documentation required to continue medications.
◦ Conduct pre-release sessions focused on linkage to community-based care and individualized goal setting.

2. Prioritize Medicaid and Benefits Enrollment: Enroll individuals in Medicaid as early as possible, ideally pre-release, when operating in states that have received a Centers for Medicare & Medicaid Services (CMS) Reentry Waiver.
◦ Ensure the released person receives support to reinstate their suspended Medicaid coverage upon release to ease the burden and promote continuity of care.
◦ Enroll eligible individuals in specialized programs like the Housing Opportunities for Persons With AIDS (HOPWA) and the Ryan White HIV/AIDS Program (RWHAP) to secure supportive housing and services.

3. Integrate Peers and Navigation Services: Incorporate peers who have lived experience of incarceration as Community Health Workers (CHWs) and members of the integrated medical team.
◦ Provide navigation and accompaniment services (in addition to case management) to support participants in attending their appointments and engaging with community-based care.

4. Ensure Immediate Post-Release Linkage: Schedule the first outpatient appointment with a community-based medical provider shortly after release (e.g., within 48 hours, as seen in Project Start PLUS).
◦ Provide essential medical services, including comprehensive physical and medical history assessments, baseline lab testing (CD4 count and viral load), and ongoing HIV care.
◦ Ensure the individual obtains necessary medications, utilizing the provision for a 30-day supply upon release.
5. Address Co-occurring Illnesses: Utilize evidence-based practices to reduce risk for individuals with co-occurring illnesses, such as substance use disorders (SUDs).
◦ Employ Medications for Opioid Use Disorder (MOUD), peer recovery specialists, and risk planning.

Methodology: This practice guides a health center in establishing a structured student and/or postgraduate clinical psychology residency program to staff clinical roles, increase client access, and provide professional development opportunities for existing staff.

To replicate this practice, a health center should follow a phased process covering strategic planning, resource assessment, recruitment, and program operation:

1. Strategic Planning and Resource Assessment.
◦ Determine the key drivers for launching the behavioral health training program (e.g., meeting the behavioral health needs of clients trained in an integrated care model, benefits to the health center, benefits to the trainee).
◦ Identify the specific training requirements based on discipline and level (e.g., practicum, internship, residency).
◦ Assess necessary resources, including physical space, human capital, and financial needs.
◦ Secure essential organizational buy-in from the board, leadership, and clinicians.
◦ Develop a financial and strategic plan, considering direct/indirect costs, long-term Return on Investment (ROI), and potential partners.

2. Program Structure and Competency Definition.
◦ Define professional competencies specific to the health center setting, such as integrated care, telebehavioral health, and OUD/SUD care.
◦ Establish the core training program elements, including clinical exposure (e.g., integrated care settings, school-based health centers, shelters) and specific requirements for direct clinical care (e.g., minimum 900 visits/year).
◦ Implement didactic seminar types, such as training on treating chronic health conditions, multicultural considerations, and conducting group treatment.
◦ Ensure required supervision meets state licensing standards (e.g., 2 hours individual, 1 hour group) and incorporates Quality Improvement (QI) training and participation in QI initiatives.

3. Recruitment and Implementation Timeline.
◦ Develop a comprehensive recruitment strategy, including building relationships with local programs, maintaining a website presence, attending academic placement fairs, and leveraging professional networks (such as APPIC for Postdocs).
◦ Implement the program according to a schedule (often following the academic year), starting with orientation and setting individual and group training goals.
◦ Trainees begin seeing clients using a ramp-up approach, starting with intakes and warm-handoffs.
◦ Conduct formal evaluations (e.g., first written evaluation in December) and structured feedback sessions or surveys (e.g., in February).
◦ Use the second half of the year for advanced activities, such as residents leading didactic seminars and participating in interviews for the next cohort, leading to hiring discussions for permanent roles.

Methodology: This practice enables a health center to evaluate its current state of health information technology interoperability across key organizational and technical domains (Technology and Data, Privacy and Security, Strategy and Governance, and Program Design) using a structured, self-assessment methodology to create a cohesive organizational data strategy and prioritize next steps for quality improvement.

To replicate this practice, health centers should implement the following steps:

1. Form the Assessment Team and Review the Tool: Assemble a multi-disciplinary team, such as an existing data governance or improvement team, to discuss and complete the score card. Review the scorecard as a whole and address any questions about terminology or internal background knowledge.

2. Conduct the Structured Self-Assessment: Systematically grade the health center's readiness across all key areas of interoperability on a scale of 1 through 5, where 1 is poorly developed and 5 is well developed.
◦ Assess Process, which refers to structured processes, policies, and procedures within the health center.
◦ Assess Infrastructure, which refers to structural capacity and ability within the health center’s technology and staffing structure.
◦ Assess Action, which refers to full implementation to the point of active and ongoing use and engagement.

3. Analyze Results and Prioritize Gaps: Use the score card results to inform next steps, addressing areas where the score indicates poor development.
◦ Prioritize improving Data Ingestion and Data Sharing capabilities using standardized formats such as HL7® V2 messages, FHIR®, and protocols like Direct Messaging.
◦ Prioritize putting appropriate safeguards in place where gaps were identified in the Security Risk Assessment (SRA).

4. Align Strategy and Ensure Governance: Use the assessment to align metrics and improvement efforts to create a cohesive organizational data strategy.
◦ Establish necessary Data Governance policies and committees, comprised of personnel from different departments, to ensure shared definitions, compliance, and specific responsibilities are assigned to data stewards.
◦ Establish organizational Interoperability Goals, which may include streamlining care by reducing duplication, improving population health management, and furthering patient safety.

5. Monitor and Re-evaluate Progress: Use the score card to guide discussions and monitor progress over time, tracking performance across key performance indicators (KPIs). Re-evaluate the scorecard once next steps have been completed.

Methodology: This practice implements a standardized, visually engaging patient education model adapted to individual needs and backgrounds to promote self-management of diabetes. The guide simplifies complex medical advice into six key self-care areas and includes forms for structured goal setting and progress tracking.

To replicate this practice, health centers and enabling staff should utilize the guide’s structure to introduce critical lifestyle changes and self-monitoring tools:

1. Introduce and Prioritize the Six Core Areas: Review the guide with the patient to emphasize the six elements necessary for managing diabetes and leading a quality life: food, activity, rest, feelings, getting regular medical checkups to track progress, and setting really clear goals.

2. Educate on Personalized Nutrition and Portion Control: Instruct the patient on healthy eating by using the visual aids provided, focusing on meals rich in vegetables and whole grains and low in fats and calories.
◦ Teach patients to use a visual cue, such as a 9-inch or 22 centimeter plate, for portion management.
◦ Detail specific foods to avoid, including all fried foods, fast foods (hamburgers, pizza, fried chicken), fatty foods (sausage, cheese, hot dogs, lard), high-sugar foods (ice cream, cakes, cookies), canned meats (Spam, deli meats), and sweetened or alcoholic beverages.

3. Develop a Safe and Consistent Exercise Plan: Encourage the patient to start slowly, exercising at least 10 minutes a day at their own pace, adding time and activities gradually.
◦ Advise patients that exercise can be done anywhere, including lifting weights with bottles filled with water or sand, using a chair for exercise, or jogging lightly in place.
◦ Provide safety instructions, including exercising 1-3 hours after eating (when blood sugar is highest), bringing something sugary (candy, juice) in case blood sugar drops, and staying hydrated.

4. Enforce Daily Foot Care Protocols: Emphasize that people with diabetes must be careful with their feet and implement daily safety checks.
◦ Patients must wash their feet daily with soap and warm water, dry them well (especially between toes), and keep skin moisturized with cream (but not between the toes).
◦ Instruct patients to use a mirror or ask for help to check for wounds, cut nails straight across, wear clean stockings, and avoid walking barefoot inside or outside the house.
5. Address Emotional and Social Support Needs: Encourage the patient to manage stress, tension, and feelings of isolation by seeking support.
◦ Suggest talking with friends, a spiritual guide, or a healthcare provider about difficult feelings.
◦ Encourage the patient to maintain communication with family, even those far away, as sharing plans can make them feel and see things differently.
6. Utilize Goal Tracking and Monitoring Forms: Use the goal setting forms provided in the guide to standardize patient follow-up and monitoring.
◦ Emphasize that the A1c (average blood sugar in the last 3 months) should be checked every 6 months.
◦ Have the patient write down specific, achievable goals related to A1c tracking, taking medications, exercise, eating healthy, and controlling their weight.

Methodology: This practice implements a standardized, visually engaging patient education model adapted to individual needs and backgrounds to promote self-management of diabetes. The guide simplifies complex medical advice into six key self-care areas and includes forms for structured goal setting and progress tracking.

To replicate this practice, health centers and enabling staff should utilize the guide’s structure to introduce critical lifestyle changes and self-monitoring tools:

1. Introduce and Prioritize the Six Core Areas: Review the guide with the patient to emphasize the six elements necessary for managing diabetes and leading a quality life: food, activity, rest, feelings, getting regular medical checkups to track progress, and setting really clear goals.

2. Educate on Personalized Nutrition and Portion Control: Instruct the patient on healthy eating by using the visual aids provided, focusing on meals rich in vegetables and whole grains and low in fats and calories.
◦ Teach patients to use a visual cue, such as a 9-inch or 22 centimeter plate, for portion management.
◦ Detail specific foods to avoid, including all fried foods, fast foods (hamburgers, pizza, fried chicken), fatty foods (sausage, cheese, hot dogs, lard), high-sugar foods (ice cream, cakes, cookies), canned meats (Spam, deli meats), and sweetened or alcoholic beverages.

3. Develop a Safe and Consistent Exercise Plan: Encourage the patient to start slowly, exercising at least 10 minutes a day at their own pace, adding time and activities gradually.
◦ Advise patients that exercise can be done anywhere, including lifting weights with bottles filled with water or sand, using a chair for exercise, or jogging lightly in place.
◦ Provide safety instructions, including exercising 1-3 hours after eating (when blood sugar is highest), bringing something sugary (candy, juice) in case blood sugar drops, and staying hydrated.

4. Enforce Daily Foot Care Protocols: Emphasize that people with diabetes must be careful with their feet and implement daily safety checks.
◦ Patients must wash their feet daily with soap and warm water, dry them well (especially between toes), and keep skin moisturized with cream (but not between the toes).
◦ Instruct patients to use a mirror or ask for help to check for wounds, cut nails straight across, wear clean stockings, and avoid walking barefoot inside or outside the house.
5. Address Emotional and Social Support Needs: Encourage the patient to manage stress, tension, and feelings of isolation by seeking support.
◦ Suggest talking with friends, a spiritual guide, or a healthcare provider about difficult feelings.
◦ Encourage the patient to maintain communication with family, even those far away, as sharing plans can make them feel and see things differently.
6. Utilize Goal Tracking and Monitoring Forms: Use the goal setting forms provided in the guide to standardize patient follow-up and monitoring.
◦ Emphasize that the A1c (average blood sugar in the last 3 months) should be checked every 6 months.
◦ Have the patient write down specific, achievable goals related to A1c tracking, taking medications, exercise, eating healthy, and controlling their weight.

Methodology: This practice implements a standardized, visually engaging patient education model adapted to individual needs and backgrounds to promote self-management of diabetes. The guide simplifies complex medical advice into six key self-care areas and includes forms for structured goal setting and progress tracking.

To replicate this practice, health centers and enabling staff should utilize the guide’s structure to introduce critical lifestyle changes and self-monitoring tools:

1. Introduce and Prioritize the Six Core Areas: Review the guide with the patient to emphasize the six elements necessary for managing diabetes and leading a quality life: food, activity, rest, feelings, getting regular medical checkups to track progress, and setting really clear goals.

2. Educate on Personalized Nutrition and Portion Control: Instruct the patient on healthy eating by using the visual aids provided, focusing on meals rich in vegetables and whole grains and low in fats and calories.
◦ Teach patients to use a visual cue, such as a 9-inch or 22 centimeter plate, for portion management.
◦ Detail specific foods to avoid, including all fried foods, fast foods (hamburgers, pizza, fried chicken), fatty foods (sausage, cheese, hot dogs, lard), high-sugar foods (ice cream, cakes, cookies), canned meats (Spam, deli meats), and sweetened or alcoholic beverages.

3. Develop a Safe and Consistent Exercise Plan: Encourage the patient to start slowly, exercising at least 10 minutes a day at their own pace, adding time and activities gradually.
◦ Advise patients that exercise can be done anywhere, including lifting weights with bottles filled with water or sand, using a chair for exercise, or jogging lightly in place.
◦ Provide safety instructions, including exercising 1-3 hours after eating (when blood sugar is highest), bringing something sugary (candy, juice) in case blood sugar drops, and staying hydrated.

4. Enforce Daily Foot Care Protocols: Emphasize that people with diabetes must be careful with their feet and implement daily safety checks.
◦ Patients must wash their feet daily with soap and warm water, dry them well (especially between toes), and keep skin moisturized with cream (but not between the toes).
◦ Instruct patients to use a mirror or ask for help to check for wounds, cut nails straight across, wear clean stockings, and avoid walking barefoot inside or outside the house.
5. Address Emotional and Social Support Needs: Encourage the patient to manage stress, tension, and feelings of isolation by seeking support.
◦ Suggest talking with friends, a spiritual guide, or a healthcare provider about difficult feelings.
◦ Encourage the patient to maintain communication with family, even those far away, as sharing plans can make them feel and see things differently.
6. Utilize Goal Tracking and Monitoring Forms: Use the goal setting forms provided in the guide to standardize patient follow-up and monitoring.
◦ Emphasize that the A1c (average blood sugar in the last 3 months) should be checked every 6 months.
◦ Have the patient write down specific, achievable goals related to A1c tracking, taking medications, exercise, eating healthy, and controlling their weight.

Methodology: This practice enables a health center to retain talented behavioral health (BH) staff and build internal management capacity by creating structured career pathways and providing dedicated leadership training and mentorship.

To replicate this practice, an organization should focus on developing structures that promote and prepare current BH practitioners for leadership roles:

1. Assess Agency Needs and Staff Skills.
◦ Determine the specific roles the agency needs to accomplish its goals.
◦ Identify staff skills and interests to see where they can exercise their expertise.
◦ Identify what scaffolding is in place to support career development.

2. Establish Career Pathways and Promotion Structure.
◦ Develop pathways for current BH practitioners to become leaders, such as a progression from Therapist to Lead/Senior Therapist to Program Manager.
◦ Implement Horizontal Job Promotion to show the organization values career growth and rewards effort. Horizontal promotion involves increasing the title and pay with little to no change in responsibilities (e.g., Therapist to Lead Therapist).

3. Develop and Utilize Leadership Training.
◦ Create a leadership training manual or curriculum.
◦ Leverage existing resources, such as an EAP Provider or the Google Project Management Professional Certificate.
◦ Utilize BH staff's existing graduate-level training, which often includes clinical skills, systems understanding, research and data analysis, and teaching skills, for broader agency leadership roles.

4. Build Opportunities and Identify Leaders.
◦ Identify emerging leaders starting at recruitment, hiring, and onboarding.
◦ Encourage movement along career pathways.
◦ Provide mentorship focused on specific tasks and projects.
◦ Ensure annual appraisals include stretch goals that go beyond documentation and productivity.
◦ Secure funding sources such as grants and foundations to support these efforts.

Methodology: This practice implements a bi-directional medical and dental integration model, initially piloted at a single, co-located site, to ensure diabetic patients receive both medical and oral health services, which supports improved chronic disease outcomes. The methodology leverages training, streamlined workflows, and shared data.

To replicate this practice, health centers should implement the following steps:

1. Establish a Small, Co-located Pilot Team: Start the initiative as a pilot project at a single clinic site where medical and dental services are co-located, and use quality improvement methodologies like small-scale tests to implement new workflows.

2. Implement Bi-Directional Training: Ensure cross-training occurs between departments:
◦ Train the medical team (PCPs, MAs, Nurses) on how to conduct a limited oral health evaluation and how to schedule dental appointments.
◦ Train the dental team on A1c lab testing protocols, including where to find A1c results and how to order an overdue A1c lab using the EHR (EPIC).

3. Integrate Oral Health Risk Assessment into Medical Visits: During the medical visit, provide education on the diabetes/oral health relationship and conduct a short oral health risk assessment.
◦ Utilize a streamlined, short risk assessment tool (e.g., three questions) to minimize the time burden on the medical team, capturing results using EHR forms (e.g., Smart Phrases in EPIC).

4. Ensure Direct Dental Scheduling: Optimize the referral process by having the medical assistant make a follow-up dental appointment directly into the dental schedule before the patient leaves the medical exam room.

5. Utilize Dental Visits for Diabetes Tracking: During subsequent dental appointments, the dental team should check the date of the patient’s last A1c test and, if needed, ensure the patient stays up-to-date by ordering an overdue A1c lab.

Methodology: This practice implements a medical and dental integration model by training primary care providers (PCPs) on oral health competencies, establishing joint workflows, and utilizing strategies like same-day scheduling to increase the number of patients with diabetes who access both medical and dental care.

To replicate this practice, health centers should implement the following steps:

1. Establish Focus Population and Guidelines: Select a specific population of focus (e.g., patients with diabetes) and establish related clinical guidelines, such as an appropriate A1C range or a timeframe for the last dental visit.

2. Build a Collaborative Team and Train Staff: Identify an integration team including nurses, certified nurse practitioners, dentists, dental hygienists, and front desk staff.
◦ Have dental providers train PCPs on the importance of oral health and how to perform core clinical competencies.
◦ Hold regular meetings between medical and dental teams to establish standardized workflows and procedures.

3. Integrate Oral Health into Medical Visits: During the primary care visit, PCPs should engage in oral health activities.
◦ PCPs ask the patient about their dental home and the date of their last dental visit, documenting the responses in the Electronic Medical Record (eClinicalWorks/eCW).
◦ PCP administers fluoride varnish applications and conducts an oral screening evaluation, documenting the findings in eCW.
◦ PCP utilizes an internal electronic referral process (via Dentrix) to send a referral to the dental department.

4. Optimize Scheduling and Referral Follow-Up: Use strategies to ensure patients schedule and keep dental appointments.
◦ Front office staff or dental hygienists should proactively review the PCP schedule to identify patients with diabetes needing dental care.
◦ If a patient with diabetes does not have a dental home, the medical team connects them with dental schedulers before they leave the clinic.
◦ Utilize small-scale tested strategies such as scheduling same day visits or having the PCP personally walk the patient to the front desk to increase appointment attendance.
5. Integrate Diabetes Information into Dental Visits: The dental team should engage in complementary integration.
◦ During a dental visit, team members ask about the date of the patient’s most recent diabetes check-up, the latest A1C level, and how often they test their blood sugar.
◦ Dental assistants check the patient's last diabetes check and A1C level through eCW.
◦ The dental team coordinates care with the medical team if the patient has a high A1C and is scheduled for invasive dental treatment.
◦ Utilize a developed workflow decision tree for patients with diabetes to guide treatment decisions.

Methodology: This practice enables health centers to integrate HIV/HCV prevention and testing into MOUD care settings, building patient trust and providing essential wraparound services to reduce infection risk and support patient stability.

To replicate this practice, an organization should implement the following steps:

1. Standardize Routine Testing and Documentation.
◦ Integrate routine HIV and HCV testing into the MOUD intake process.
◦ Embed reminders into Electronic Health Records (EHRs) to support consistent testing and timely follow-up.

2. Ensure Staff Training and Patient-Centered Approach.
◦ Train all staff annually in Motivational Interviewing (MI) principles to ensure consistent use of this standard of care.
◦ Utilize a respectful, patient-centered approach that focuses on building trust and stability.
◦ Employ peer support to help patients navigate care with empathy.

3. Establish Comprehensive Care and Referral Pathways.
◦ Establish strong referral pathways for mental health and behavioral health support.
◦ Utilize community organizations to establish strong partnerships for wraparound services (e.g., housing, employment, food assistance).
◦ Collaborate with community partners to provide safer use supplies.

4. Define Partnership Workflows.
◦ Establish clear workflows and shared goals with partners to support patient connection to services and reduce care gaps.
◦ Facilitate warm hand-offs to community partners to maintain patient engagement.

Methodology: This practice incorporates structured protocols and counseling rubrics, delivered by multidisciplinary teams, to address both the physiological and behavioral aspects of tobacco dependence and to improve outcomes across various settings.

To replicate this practice, a health center should follow these steps:

1. Implement Guideline-Recommended Counseling
◦ Use the five A's rubric (Ask, Advise, Assess, Assist, Arrange) or shorter rubrics like Ask-Advise-Refer (A&R) or Ask-Advise-Connect (A&C) as the hallmark of the counseling portion.
◦ Offer brief counseling interventions (3–5 minutes) or more intensive interventions (more than 15 minutes) in both clinical and nonclinical settings, recognizing that addressing tobacco use improves mental health.
◦ Train Community Health Workers (CHWs) or lay health workers to deliver the 5A model to provide consistent messaging across the patient's care team.

2. Utilize Patient Navigation for Care Coordination
◦ Deploy patient navigators (non-clinical staff with specialized training) to guide high-risk individuals through complex health systems, especially for multi-step prevention processes like lung cancer screening.
◦ Ensure navigators follow a structured, patient-centered protocol including providing education, facilitating shared decision-making visits with primary care providers (PCPs), assisting with appointment scheduling, arranging follow-up, and offering cessation support.
◦ Focus on the interpersonal qualities of navigators, such as reliability, kindness, and clear communication, as these qualities provide vital emotional and tangible support for complex care.

3. Address Youth-Specific Needs
◦ Screen all young people often, using validated screening tools like S2BI (Screening to Brief Intervention) or CRAFT, which includes questions on nicotine use and markers of addiction (e.g., using alone, using to feel relaxed).
◦ Meet young people where they are at on the continuum of use, using a person-centered intervention that is fact-based and avoids scare tactics.
◦ Provide resources based on motivational interviewing and cognitive behavioral therapy, such as the Healthy Futures cessation program, to move youth toward quitting.
◦ Consider prescribing FDA-approved medications (like Nicotine Replacement Therapy) off-label for youth under 18 with high nicotine dependence, recognizing that it is safe and efficacious when combined with counseling.

4. Incorporate Pharmacotherapy and Objective Measurement
◦ Offer FDA-approved pharmacotherapy (nicotine replacement therapy, varenicline, and bupropion) in combination with counseling, recognizing that combination therapy is generally preferred and treatment duration can be extended up to a year.
◦ Use medications to reduce withdrawal symptoms and induce cessation attempts.
◦ Use objective measures like carbon monoxide breath tests or salivary cotinine levels in cessation trials to track abstinence and support the establishment of benchmarks.
◦ Ensure medications are offered to patients with serious mental illness, as clinical trials confirm these medications are safe and effective for this population.

Methodology: This practice utilizes a detailed Memorandum of Understanding (MOU) template to formalize roles, responsibilities, and resource sharing between a Health Center and a Domestic Violence/Sexual Assault/Human Trafficking (DV/SA/HT) CBO to strengthen collaboration, promote patient safety, and ensure bidirectional warm referrals for patients and staff.

To replicate this practice, organizations should implement the following steps:

1. Formalize the Partnership and Define Purpose: Establish the agreement by having designated agents from both the Health Center (HC) and the DV/SA/HT/CBO agency sign the MOU.
◦ Define the core purpose of the collaboration, such as strengthening staff collaboration, promoting health and safety outcomes, and coordinating services including health enrollment and transportation.

2. Define Mutual Roles and Responsibilities: Clearly outline the specific duties and roles for each entity within the MOU structure.
◦ HC Responsibilities: Include serving as a primary healthcare referral for clients, training DV/SA/HT/CBO advocates on health center enrollment and services, and drafting and reviewing IPV/HT policies and procedures.
◦ DV/SA/HT/CBO Responsibilities: Include training health center providers and staff on DV/HT dynamics and community supports, serving as a primary referral for HC patients or staff in need, and offering advocacy support (onsite or virtual via telehealth).

3. Commit Resources and Structure Meetings: Ensure the partnership is supported by dedicated resources and consistent communication.
◦ List specific resources (e.g., additional staff time, mobile health services, office space for co-located advocates, 24/7 hotline support) that each entity will provide to support the project’s efforts.
◦ Schedule initial and recurring meetings between representatives of both agencies to understand services, discuss needs, and maintain the recurring schedule.

4. Establish Tracking and Evaluation Mechanisms: Agree on tools to measure the success and challenges of the collaboration and outcomes.
◦ Agree to review and discuss evaluation tools, such as a referral tracking tool and a Quality Assessment/Quality Improvement tool used every six months.
◦ Include plans for collecting data via client/patient satisfaction surveys and provider/staff training evaluations.

Methodology: This practice uses mobile medical units or street outreach teams (backpack medicine) to meet communities with additional needs directly in their environments (encampments, overpasses, streets), providing immediate primary and specialized care (HIV/Hepatitis C testing, wound care, MAT) to build trust and facilitate linkage to sustained brick-and-mortar services.

To replicate this practice, a health center should follow these steps:

1. Conduct Community Assessment and Partnership
◦ Meet with existing community-based organizations (CBOs) and other mobile medical units to coordinate efforts and avoid duplicating services.
◦ Survey intended clients (members) to get input on services, location, and branding to ensure comfort and increase utilization.
◦ Establish strong, frequent collaborations with community partners, including hospitals (specifically emergency rooms), police, fire, and EMS.

2. Define Program Mission and Prepare Infrastructure
◦ Dedicate time (up to a year) before deployment to research, read, and define the mission, specific services (e.g., HIV/Hepatitis C testing, wound care, overdose prevention), and target areas.
◦ Comply with all local laws and ordinances regarding testing waivers, additional insurance liability, ADA requirements, and restrictions on operating near schools or parks.
◦ When purchasing vehicles, seek input from peers and references, and consider buying used units or smaller vehicles (like golf carts or vans) for hard-to-reach encampments.
◦ Design the mobile unit for flexibility, including dual exam rooms, full medical exam capabilities, medical refrigerators, and secure lockboxes for medications (like PrEP).
◦ Ensure the unit has essential infrastructure like a generator that runs the entire unit, reliable Wi-Fi/connectivity, and two air conditioning and heating units for year-round service.

3. Implement Outreach and Trust-Building Strategies
◦ Staff the unit with a multi-disciplinary team, including physicians, nurses, case managers, intake staff, and peers, to provide real-time services and warm hand-offs.
◦ Prioritize building trust by engaging community members with compassion, respect, empathy, and dignity, meeting them where they are at.
◦ Use tools of engagement, such as hygiene packs, water, over-the-counter medications, and pet treats, to address basic needs before clinical care.
◦ Ensure vehicle branding avoids stigmatizing language and logos, as client discomfort can prevent them from utilizing the service.
◦ Provide real-time services such as Rapid ART and same-day prescription refills, helping newly diagnosed individuals achieve viral suppression faster.

4. Ensure Financial Sustainability and Oversight
◦ Look for non-restricted grants and community sponsorships (e.g., pharmacies) to build a sustainable budget that can survive the loss of a single grant.
◦ Factor high operational costs into the budget, including gas, repairs, and unexpected expenses (like replacing a generator engine).
◦ Hire a dedicated fleet manager to manage maintenance, routine oil changes, and upkeep, treating the unit as a key asset.
◦ Track key performance metrics, including billable versus unbillable services, and continuity of care (e.g., the percentage of individuals achieving three or more visits).
◦ Ensure all staff are well-trained on equipment use, medical compliance (HIPAA, OSHA), and safety procedures.

Methodology: This practice standardizes the initial screening for head, neck, or face injuries, associated behavioral health issues, and community health factors through a structured, advocate-led questionnaire (CHATS) developed by the Ohio Domestic Violence Network (ODVN) and The Center on Partner-Inflicted Brain Injury.

To replicate this practice, service providers should partner with groups or providers to administer the CHATS form and use the results to coordinate support services and create an individualized CARE plan:

1. Screen the individual using the CHATS form: Administer the questionnaire with an advocate to assess if the individual was hit or hurt in the head, neck, or face, including through choking or strangulation.

2. Document injury and altered consciousness: Record if the individual experienced altered consciousness, such as feeling dazed, confused, dizzy, or blacking out, as well as the approximate number of times they have been hurt.

3. Identify current struggles and clinical needs: Assess current troubles across Physical (e.g., headaches, fatigue), Emotional (e.g., depression, anger), and Thinking (e.g., remembering, organizing) domains, and explicitly screen for struggling with alcohol or drugs and having thoughts of suicide.

4. Assess access barriers: Use the ACCESS TO section to identify immediate challenges related to daily life, including Housing, Employment, Food, Utilities, and Health Care/Insurance.

5. Develop and implement the CARE plan: Create a CARE (Connect, Acknowledge, Respond, Evaluate) plan with the advocate and implement tailored response strategies based on identified struggles.
◦ Adjust services to implement accommodations like scheduling shorter, more frequent meetings, creating checklists or calendars, or assigning a ground floor room for balance challenges.
6. Provide supporting educational resources: Offer the individual the JUST BREATHE wellness journal and the INVISIBLE INJURIES guide, which contain self-care ideas and coping strategies for common challenges.

Methodology: This practice enables a health center to improve maternal and newborn health outcomes in the critical fourth trimester (the first 12 weeks after birth) by integrating screening for social and medical needs, providing education, and coordinating care with community partners. This structured approach addresses the high rate of maternal morbidity and mortality that can occur during this period.

To replicate this practice, an organization should formalize a process that includes screening, care coordination, and continuous partnership:

1. Integrate Screening for Challenges.
◦ Review postpartum medical needs, screening, patient education, and community support to identify potential complications or medical concerns.
◦ Screen for patient challenges that impact health and well-being, such as those related to Economic Stability, Neighborhood and Physical Environment, Education, and Food Safety.
◦ Utilize validated social needs screening tools such as PRAPARE, the EveryONE Project tool, and the CMS Health-Related Social Needs Screening Tool.

2. Formalize Warm Hand-offs and Care Coordination.
◦ Formalize a process within the organization or community to provide warm hand-offs for patients in the fourth trimester.
◦ Develop a dyadic strategy for the maternal-newborn dyad that includes continuous support, coordinated care between different providers, strong emphasis on early attachment, and integration of physical and mental healthcare for both mother and baby.
◦ Embed enrollment into care plans by ensuring care plans include standing on enrollment during visits, and regular monitoring by Medicaid-managed care organizations (MCOs).

3. Develop and Leverage Community Partnerships.
◦ Identify programs in the area and develop relationships with local community resource programs (e.g., local WIC office, churches, and schools).
◦ Partner with community champions, such as Baby2Baby (provides maternal health and newborn kits) and ShareBaby (distributes diapers and other essentials).
◦ Establish referrals to evidence-based home visiting models like Family Connects International, Healthy Families America (HFA), and Healthy Start (HS), which provide trust-based support and address health, economic, and parenting needs,,,.
◦ Collaborate with community partners to enhance participant engagement and explore re-engagement opportunities for participants lost to care.

4. Measure and Evaluate Program Impact.
◦ Identify the metrics that can measure the impact of the fourth-trimester strategy.
◦ Monitor key metrics by consistently tracking referrals to enrollment rates and measuring and analyzing retention rates in home visiting programs.
◦ Host quarterly meetings with partners to measure the impact of the partnership.

Methodology: This practice enables a health center to define, staff, manage the clinical workflow, and measure the effectiveness and financial sustainability of an Integrated Behavioral Health (IBH) program in primary care.

To replicate this practice, an organization should execute a phased approach focused on structure, workforce, workflow, and long-term sustainability:

1. Define the Integrated Behavioral Health Model (Groundwork).
◦ Determine the organization's current landscape of IBH integration along the continuum of care, selecting the appropriate level of collaboration (Level 1 Minimal to Level 6 Full Collaboration).
◦ Adopt the five core IBH principles: ensuring patient-centric care, defining clear goals/measures (treatment to focus on), using evidence-based behavioral treatments, conducting efficient team care, and establishing population-based care.
◦ Identify the core integrated care team members, including Primary Care Physicians/NPs/PAs, Behavioral Health Clinicians (Psychologists, Social Workers), and Allied Health Professionals (Community Health Workers).

2. Implement Targeted Recruitment and Onboarding Strategies.
◦ Create job descriptions that accurately reflect the IBH role and responsibilities, aligning them with IBH core competencies (e.g., systems-oriented practice, collaboration, and quality improvement).
◦ Use specific recruitment methods, such as alumni boards of local educational institutions that train IBH clinicians or conferences promoting integrated care.
◦ Utilize unique interview questions that assess characteristics like flexibility, growth mindset, and willingness to take an active role in clinic-wide quality improvement efforts.
◦ Develop a comprehensive onboarding checklist that ensures the new IBH clinician is embedded in primary care and that systems are updated (e.g., updating consent language to include behavioral health as part of medical consent).

3. Establish Efficient Clinical Workflows.
◦ Implement universal screening for the entire patient population annually (e.g., PHQ-9, GAD7, Substance Use).
◦ Structure the IBH clinician’s day to include pre-visit planning and rotating huddles with the care teams.
◦ Ensure warm hand-offs for every patient with a positive IBH screen.
◦ Adopt short-term, evidence-based treatment models typically ranging from 6–8 visits per care episode.
◦ Schedule appointments efficiently (e.g., 30-minute visits, targeting 9–11 visits per day) using an open-access schedule that allows for same-day appointments.

4. Measure Success and Ensure Sustainability.
◦ Establish a Year 1 Sustainability Plan covering operational, clinical, cultural, and financial actions (e.g., setting workflows, training primary care teams, monitoring early financial performance).
◦ Define key outcome metrics (e.g., PHQ-9 improvement, access rates) and use Quality Improvement (QI) measures, such as Plan-Do-Study-Act (PDSA) cycles, to drive improvement.
◦ Measure integration success over time using validated tools across organizational (e.g., MeHAF Site Self-Assessment Evaluation Tool) and clinician domains (e.g., Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ)).
◦ Ensure all roles able to bill are billing from the outset while ramping up, and secure buy-in from payers for reimbursement models (e.g., grants, FFS, PPS, or bundled payments).

Methodology: This practice enables a health center to build local employment capacity and address dental assistant (DA) shortages by implementing a formal, structured, on-the-job DA training program.

To replicate this practice, a health center should follow a phased process to assess readiness, secure resources, and design a customized training program:

1. Evaluate Need and Organizational Readiness.
◦ Determine the local and internal need for DAs, noting that 74% of dental leaders have reported a DA shortage.
◦ Research local and state regulations regarding DA, Infection Prevention and Control (IPC), radiology, and certification requirements.
◦ Assess the health center’s overall capacity, including physical space (e.g., operatories), financial resources (e.g., ability to sustain the program while ramping up), and workforce (willing and supportive team).

2. Engage Stakeholders and Establish Leadership.
◦ Secure essential organizational buy-in from key stakeholders, including the CEO, Human Resources director, and, critically, existing dental assistants and the dental team.
◦ Select program implementation leaders, often dental directors or office managers, who are passionate about teaching or program management.

3. Develop Budget and Funding Strategy.
◦ Create an initial budget outlining one-time startup costs (which can range from $2,000 to $169,000) and an operating budget for ongoing costs.
◦ Identify funding sources, which typically include the organization-wide or dental department budget, and allocate funds for equipment, teaching materials, and certification classes (like radiology or infection control).

4. Design Curriculum and Training Structure.
◦ Define the program's frequency, length (most interviewed programs are four to six weeks), scope, and size.
◦ Design the curriculum to align with state regulations, covering didactic content (e.g., terminology, anatomy) and clinical components (e.g., IPC, radiology, EDR training, and procedures).
◦ Identify trainers, noting that they are often existing DAs, and ensure they are equipped with the resources they need to teach trainees.
5. Implement Recruitment, Competency Assessment, and Retention.
◦ Establish trainee requirements (e.g., 18 years old or older, high school diploma/GED).
◦ Implement recruitment strategies, including internal recruitment (existing staff) and external outreach (community postings, patient base).
◦ Develop competency assessments using checklists, quizzes, exams, or by embedding the training into regular clinic competency procedures, such as 30-60-90-day reviews.
◦ Develop a retention strategy, such as establishing career ladders to provide upward mobility, offering competitive salaries/benefits, or using employment contract clauses.
6. Evaluate and Refine the Program.
◦ Evaluate the program by documenting the recruitment rate (trainees hired/total trainees) and retention rate (trainees remaining/total trainees).
◦ Collect feedback via satisfaction surveys from trainees and trainers.
◦ Use ongoing communication and feedback to continually re-evaluate and refine the program.

Methodology: This practice equips health centers to implement youth-centered health care by integrating social and emotional screening, trust-building techniques, flexible access points, and community partnerships to serve adolescent and young adult patients.

To replicate this practice, a health center should follow these steps:

1. Systematically Collect Data and Build Trust
◦ Routinely use validated screening tools, such as the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE®) and the Hunger Vital Sign™, to assess family dynamics, economic resources, and social factors.
◦ Document and track these social and economic factors in the electronic health record using ICD-10 Z-codes (Z55-Z65).
◦ Develop organization-wide policies that explain how data flows, how it is secured, and how patient data will be used and protected, and communicate these processes clearly to patients.
◦ Focus on building authentic relationships with youth by practicing honesty, respect, and empathy, and using shared decision-making guided by the patient's self-directed goals.

2. Integrate Mental Health and Practices Responsive to Adverse Experiences
◦ Integrate mental health professionals into the primary care team or ensure that primary care and mental health care are accessible at one location.
◦ Train primary care teams to routinely screen for mental health challenges and provide early interventions, warm hand-offs, or referrals to mental health professionals.
◦ Implement universal protocols for responding to disruptive behaviors, recognizing that these behaviors are often maladaptive responses to stress.
◦ Utilize healing-centered engagement by focusing on the patient's assets and strengths rather than weaknesses, and celebrating milestones.

3. Enhance Access and Support Autonomy
◦ Offer flexible scheduling options, including drop-in hours for certain services and adjusted or eliminated late arrival policies for youth.
◦ Provide evening and/or weekend appointments to accommodate youth schedules, and use digital methods like online scheduling, telehealth, and text messaging for appointment and medication reminders.
◦ Create resources that help youth become autonomous managers of their health care by learning to navigate the system (e.g., scheduling, referrals, patient portals) and proactively manage their health needs (e.g., track prescription refills).

4. Engage Youth and Formalize Partnerships
◦ Form Youth Community Advisory Groups (YCAGs) to provide regular input and feedback on health center services, programs, and decisions.
◦ Remove barriers to YCAG participation by offering food, transportation, small stipends, and flexible meeting formats (virtual, in-person, or hybrid).
◦ Partner with community organizations (e.g., schools, housing, behavioral health) to align services and share resources.
◦ Formalize these collaborations through a Memorandum of Understanding (MOU) that establishes a standard system for bidirectional referrals.