Comagine Health

WASHINGTON AND IDAHO REGIONAL EXTENSION CENTER PROGRAM

SURVEILLANCE OF BURDEN ON PATIENTS POST-COVID-19 - PROJECT ABSTRACT SUMMARY COMAGINE HEALTH, A 501(C)(3) NONPROFIT ORGANIZATION, IS THRILLED TO SUBMIT THIS APPLICATION TO THE COMPONENT A SCOPE OF WORK. WE HAVE WORKED WITH FEDERAL AND STATE CLIENTS TO IMPLEMENT ANALYTICS SOLUTIONS FOR THE BETTERMENT OF HEALTHCARE FOR OVER 40 YEARS. AS ONE OF THE COMPONENT A AWARDEES, WE WILL WORK TO ADVANCE INTEROPERABILITY AND SURVEILLANCE BY PARTNERING WITH THE OTHER COMPONENT A AND B AWARDEES AND LEVERAGING EXISTING HEALTH INFORMATION EXCHANGE (HIE) DATA. HIE DATA INCLUDE THE DIAGNOSES, PROCEDURES, CLINICAL NOTES, AND LAB VALUES RECORDED IN ELECTRONIC MEDICAL RECORDS, AGGREGATED, AND PROCESSED FOR SURVEILLANCE, ANALYSIS, AND REPORTING. OUR TEAM IS LED BY EXPERIENCED INVESTIGATORS FROM BOISE STATE UNIVERSITY’S (BSU) PUBLIC HEALTH AND POPULATION SCIENCE DEPARTMENT WITH DEEP EXPERTISE IN SURVEILLANCE AND DEVELOPING AND RUNNING COHORT STUDIES. BEYONDHIE IS OUR CONNECTION TO THE DISCRETE HIE ORGANIZATIONS THAT WILL LEAD THE DATA COLLECTION AND AGGREGATION FOR OUR APPROACH: THE UTAH HEALTH INFORMATION NETWORK (UHIN) AND BRONX REGIONAL HEALTH INFORMATION ORGANIZATION (BRONXRHIO). WE HAVE THE POSSIBILITY OF ADDING ONE TO TWO ADDITIONAL STATES (THROUGH OTHER HIE PARTNERS) PRIOR TO THE END OF THE STUDY.THIS PARTNERSHIP ARRANGEMENT LEVERAGES EXISTING PARTNERSHIPS WITH PUBLIC HEALTH AND COMMUNITY ORGANIZATIONS IN UTAH AND THE BRONX AND IMPROVES UPON DATA EXCHANGE PROCESSES BETWEEN TWO ESTABLISHED HIES. OUR APPROACH WILL ALLOW US TO MEASURE THE BURDEN, DISTRIBUTION, AND IMPACT OF POST-COVID-19 CONDITIONS (PCC) IN A RELIABLE, SCALABLE, AND POPULATION-BASED MANNER. WE WILL WORK IN TWO DISTINCT GEOGRAPHIC AREAS: COHORT 1 WILL BE DERIVED FROM A STATE-WIDE HIE WITH DATA FROM UTAH RESIDENTS; COHORT 2 WILL BE DERIVED FROM A BOROUGH-WIDE HIE WITH DATA FROM RESIDENTS OF THE BRONX, NEW YORK CITY, NEW YORK. COHORT INDIVIDUALS FROM BOTH CATCHMENT AREAS INCLUDE CHILDREN, ADOLESCENTS, AND ADULTS, REFLECT URBAN AND RURAL AREAS, SOCIO-ECONOMICALLY DIVERSE AREAS, AND INDIVIDUALS DISPROPORTIONATELY IMPACTED BY COVID-19. WE WILL IDENTIFY INDIVIDUALS WHO HAVE COVID-19 INFECTIONS AND CHARACTERIZE THE SYMPTOMS AND SEVERITY OF INFECTION WITHIN THE TWO COHORTS USING BIOPHYSICAL MEASUREMENTS, LAB RESULTS, DIAGNOSES, TREATMENTS, MEDICATIONS, AND HOSPITALIZATION DATA, AS WELL AS THE DATE OF ALL OBSERVATIONS. THESE DATA ELEMENTS WILL FURTHER BE USED TO CHARACTERIZE PRE-EXISTING CONDITIONS, AS WELL AS PCC. TO IDENTIFY SUBTLETIES OF ILLNESS BURDEN AND TRACK PROGRESSION OVER TIME WE WILL ANALYZE HEALTHCARE PROVIDER VISIT NOTES USING NATURAL LANGUAGE PROCESSING (NLP). ANALYSIS OF THESE DATA WILL DESCRIBE AND QUANTIFY THE INTENSITY AND DURATION OF FLUCTUATING POTENTIAL PCC SYMPTOMS. WE WILL ALSO ANALYZE SOCIO-ECONOMIC DATA ASSOCIATED WITH AFFECTED INDIVIDUALS’ CENSUS BLOCK TO DEPICT THE RELATIONSHIP OF SOCIAL DETERMINANTS OF HEALTH TO THE FREQUENCY AND SEVERITY OF POSSIBLE PCC CONDITIONS. RESULTS OF OUR APPROACH WILL BE SHARED REGULARLY WITH PUBLIC HEALTH AND COMMUNITY PARTNERS, COHORT A AND B COLLABORATORS, THE FUNDING AGENCY, AND OTHER PARTNERS WHO CAN USE THESE SURVEILLANCE REPORTS TO INFORM COVID-19 PREVENTION AND MITIGATION PROGRAMS.

INTEGRATED MATERNAL HEALTH SERVICES

REPLACEMENT GRANT - SCALING THE NATIONAL DIABETES PREVENTION PROGRAM IN UNDERSERVED AREAS OF NEW MEXICO, OREGON AND UTAH

ADVANCING HEALTH EQUITY FOR PRIORITY POPULATIONS WITH OR AT RISK FOR DIABETES IN HIGH NEEDS COUNTIES IN NEVADA AND OREGON THROUGH COMMUNITY INTEGRATED HEALTH NETWORKS - COMAGINE HEALTH IS SUBMITTING A PROPOSAL IN RESPONSE TO THE REQUEST FOR APPLICATIONS FOR A STRATEGIC APPROACH TO ADVANCING HEALTH EQUITY FOR PRIORITY POPULATIONS WITH OR AT RISK FOR DIABETES (CDC-RFA-DP-23-0020). WE ARE APPLYING FOR COMPONENT B. THE PROPOSED AREAS OF FOCUS INCLUDE COUNTIES IN THE FOLLOWING STATES: NEVADA (CLARK, POPULATION: 2,292,476) AND OREGON (MARION, JACKSON, LINN, DOUGLAS, YAMHILL, JOSEPHINE, LINCOLN, COMBINED POPULATION: 1,060,117). PREDIABETES AND DIABETES ARE SIGNIFICANT AND GROWING HEALTH CONCERNS. DIABETES IS THE 8TH LEADING CAUSE OF DEATH AND THE NUMBER ONE CAUSE OF KIDNEY FAILURE, LOWER LIMB AMPUTATION AND ADULT ONSET BLINDNESS. IT IS A COSTLY CONDITION, LEADING TO A TOTAL OF $327 BILLION ANNUALLY IN MEDICAL COSTS AND LOST WAGES. AS THE QUALITY INNOVATION NETWORK-QUALITY IMPROVEMENT ORGANIZATION (QIN-QIO) FOR IDAHO, OREGON, NEVADA, NEW MEXICO, UTAH, AND WASHINGTON AND A CDC 1705 RECIPIENT FOR NEW MEXICO, OREGON, AND UTAH, COMAGINE HEALTH HAS BEEN WORKING TO PREVENT AND SLOW THE PROGRESSION OF DIABETES BY INCREASING ACCESS TO RECOGNIZED LIFESTYLE CHANGE PROGRAMS FOR OVER FIVE YEARS AND DIABETES SELF-MANAGEMENT EDUCATION FOR OVER 20 YEARS. WE WORK WITH TRUSTED LOCAL ORGANIZATIONS AND STATE LEVEL COLLABORATORS TO BUILD INFRASTRUCTURE, PROGRAMS, AND PARTICIPANT ENGAGEMENT IN LIFESTYLE CHANGE, DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT (DSMES) AND COMMUNITY SUPPORT PROGRAMS. OUR EXPERIENCE, RELATIONSHIPS, AND ESTABLISHED INFRASTRUCTURE FROM PRIOR WORK POSITIONS US AS A LEADER IN THIS SPACE. THE SELECTED COUNTIES LISTED ABOVE HAVE SIGNIFICANT DISPARITIES IN DIABETES PREVALENCE AND INCIDENCE, OBESITY PREVALENCE, AND SOCIAL VULNERABILITY. WE HAVE SERVED THESE COUNTIES AS A QIN-QIO FOR MANY DECADES AND HAVE THE ESTABLISHED PARTNERSHIPS TO MEANINGFULLY ADVANCE AND EXPAND ACCESS TO PROGRAMS AND SOCIAL NEEDS SERVICES. TO ACHIEVE THE GOALS OF THIS COOPERATIVE AGREEMENT, COMAGINE HEALTH WILL WORK WITH FIVE COLLABORATING PARTNERS: - ACCESS TO HEALTHCARE NETWORK, DIGNITY HEALTH, QUALITY TECHNICAL ASSISTANCE CENTER, SOUTHERN NEVADA HEALTH DISTRICT (CLARK COUNTY) - OREGON WELLNESS NETWORK (ALL OREGON COUNTIES) - PROVIDENCE ST. JOSEPH (JACKSON, MARION, YAMHILL) WE WILL DEVELOP CAPACITY TO REACH THE POPULATION OF 3,352,593 WITH LIFESTYLE CHANGE, DSMES AND SUPPORT PROGRAMS THROUGH EFFECTIVE MARKETING AND ENGAGEMENT CAMPAIGNS, INNOVATIVE PROVIDER REFERRAL MODELS, AND INVESTMENT IN LOCAL DELIVERY PARTNERSHIPS TO STRENGTHEN CULTURAL AND LINGUISTIC ADAPTATIONS. WE WILL BUILD UPON ESTABLISHED INFRASTRUCTURES TO INCREASE PROVIDER REFERRAL AND CHW CENTERED SERVICES TO INCREASE ENGAGEMENT AND ADDRESS SOCIAL NEEDS BARRIERS. WE WILL CONTINUE TO EXPAND CAPACITY TO USE AND INTEGRATE WITH CRITICAL HEALTH INFORMATION TECHNOLOGY TO SCALE REFERRAL AND ENROLLMENTS. BY THE END OF THE FIVE YEAR PERIOD, WE SEEK TO ACHIEVE THE FOLLOWING OUTCOMES: 1. INCREASE THE NUMBER OF ORGANIZATIONS IMPLEMENTING EVIDENCE-BASED DSMES, CDC RECOGNIZED LIFESTYLE CHANGE PROGRAMS, MEDICARE DPP, AND DSMP SUPPORT PROGRAMS, SUPPORTED BY A ROBUST BACKBONE INFRASTRUCTURE TO ADVANCE SUSTAINABILITY. 2. INCREASED ADAPTATION/TAILORING OF EFFECTIVE PROGRAMS, INCLUDING ENGAGEMENT AND OUTREACH MODELS, FOR PRIORITY POPULATIONS, INCLUDING AFRICAN AMERICANS, HISPANIC/LATINOS, ASIAN/PACIFIC ISLANDERS, AMERICAN INDIAN/ALASKA NATIVES, LOW SOCIOECONOMIC STATUS, RURAL, OLDER ADULTS, AND PEOPLE WITH DISABILITIES. 3. INCREASE IN THE NUMBER OF PATIENTS SCREENED AND REFERRED TO COMMUNITY RESOURCES THROUGH SCALING OF THE SOUTHERN NEVADA PATHWAYS COMMUNITY HUB, STRENGTHENING SDOH SCREENING AND REFERRAL STANDARDS AND PARTNERSHIPS IN OREGON, AND INTEGRATION WITH COMMUNITY INFORMATION EXCHANGES (CIE) AND HEALTH INFORMATION EXCHANGES (HIE) IN BOTH STATES. 4. INCREASE SDOH SCREENINGS IN CLINICAL SETTINGS AND REFERRAL INTO CHW SUPPORTED SERVICES. 5. INCREASE PARTICIPATION IN EVIDENCE BASED DSMES, CDC RECOGNIZED LIFESTYLE CHANGE PROGRAMS, MEDICARE DPP, AND DSMP SUPPORT PROGRAMS.

NEVADA ADMISSIONS AND TRANSITIONS OPTIMIZATION PROGRAM (ATOP) - PHASE TWO

STATE MATERNAL HEALTH INNOVATION PROGRAM

GROWING THE COMMUNITY INTEGRATED NETWORK OF OREGON TO DELIVER AND SUSTAIN EVIDENCE BASED CHRONIC DISEASE SELF-MANAGEMENT EDUCATION AND SUPPORT PROGRAMS

COMMUNITY INTEGRATED NETWORK OF NEVADA

INCREASING COLORECTAL CANCER SCREENING AND FOLLOW-UP IN RURAL IDAHO FQHCS - COMAGINE HEALTH, IN PARTNERSHIP WITH THE IDAHO COMMUNITY HEALTH CENTER ASSOCIATION (ICHCA), PROPOSES A COMPREHENSIVE, EVIDENCE-BASED INITIATIVE TO INCREASE COLORECTAL CANCER (CRC) SCREENING RATES AMONG RURAL IDAHOANS AGED 45-75 RECEIVING CARE AT FEDERALLY QUALIFIED HEALTH CENTERS (FQHCS). THIS PROJECT DIRECTLY ADDRESSES IDAHO’S CRC SCREENING GAP, WHERE RATES LAG BELOW NATIONAL AVERAGES, ESPECIALLY IN RURAL POPULATIONS. THE INITIATIVE TARGETS FIVE FQHCS WITH SCREENING RATES BELOW THE NATIONAL AVERAGE COLLECTIVELY SERVING 121,519 PATIENTS, FOCUSING ON EVIDENCE-BASED INTERVENTIONS (EBIS) AND SUSTAINABLE QUALITY IMPROVEMENT (QI) PRACTICES. PURPOSE: TO INCREASE CRC SCREENING RATES, REDUCE SCREENING DISPARITIES, AND IMPROVE FOLLOW-UP CARE IN RURAL IDAHO THROUGH EVIDENCE-BASED INTERVENTIONS AND SYSTEM-LEVEL IMPROVEMENTS. STRATEGIES AND ACTIVITIES: COMAGINE HEALTH WILL EMPLOY A PHASED, COHORT-BASED MODEL OVER FIVE YEARS, ENGAGING TWO COHORTS OF FQHCS. COHORT 1 WILL PARTICIPATE FOR 2.5 YEARS, THEN TRANSITION TO A MENTORSHIP ROLE FOR COHORT 2. COHORT 2 WILL PARTICIPATE FOR THE FINAL 2.5 YEARS. THE PROJECT WILL IMPLEMENT THE FOLLOWING CORE STRATEGIES: • COLLABORATIVE OUTREACH & READINESS ASSESSMENT: IDENTIFY AND RECRUIT FQHCS, CONDUCT READINESS ASSESSMENTS, AND ENGAGE COMMUNITY-BASED ORGANIZATIONS TO REDUCE STRUCTURAL BARRIERS (E.G., TRANSPORTATION AND FINANCIAL ASSISTANCE FOR COLONOSCOPIES). • LEARNING COLLABORATIVE FOR EBI IMPLEMENTATION: FACILITATE QUARTERLY LEARNING SESSIONS AND PROVIDE MONTHLY 1:1 TECHNICAL ASSISTANCE USING THE IHI BREAKTHROUGH SERIES MODEL. EBIS INCLUDE PATIENT REMINDERS, PROVIDER REMINDERS, PROVIDER ASSESSMENT AND FEEDBACK, AND PATIENT NAVIGATION. • MONITORING AND EVALUATION: TRACK CRC SCREENING AND FOLLOW-UP DATA VIA THE AZARA POPULATION HEALTH SYSTEM (WHICH UTILIZES EHR DATA), CONDUCT REGULAR DATA VALIDATION, AND PRODUCE QUARTERLY PERFORMANCE REPORTS. • SUPPORT FOR TEST COMPLETION AND FOLLOW-UP: PROVIDE UNINSURED PATIENTS WITH FREE STOOL TEST KITS AND LIMITED FINANCIAL SUPPORT FOR COLONOSCOPIES. ESTABLISH PARTNERSHIPS WITH ENDOSCOPY CENTERS TO ENSURE TIMELY FOLLOW-UP. OUTCOMES: BY PROJECT END, COMAGINE HEALTH EXPECTS TO ACHIEVE: • INCREASED IMPLEMENTATION AND ENHANCEMENT OF EBIS ACROSS ALL PARTICIPATING FQHCS. • HIGHER RATES OF STOOL TEST RETURNS AND COLONOSCOPY COMPLETIONS. • A MEASURABLE INCREASE IN OVERALL CRC SCREENING RATES AMONG PATIENTS AGED 45-75. • ENHANCED FQHC CAPACITY FOR DATA-DRIVEN QUALITY IMPROVEMENT AND SUSTAINABLE EBI INTEGRATION. EVALUATION AND IMPACT: THE PROJECT WILL USE A MIXED-METHODS EVALUATION FRAMEWORK, COMBINING QUANTITATIVE DATA FROM EHR SYSTEMS WITH QUALITATIVE INSIGHTS FROM FQHCS. PERFORMANCE WILL BE MEASURED QUARTERLY, FOCUSING ON EBI IMPLEMENTATION, SCREENING RATES, AND FOLLOW-UP COMPLETION. CONTINUOUS QUALITY IMPROVEMENT CYCLES WILL DRIVE MID-COURSE ADJUSTMENTS AND SUSTAIN PROGRESS. COLLABORATION AND SUSTAINABILITY: COMAGINE HEALTH WILL PARTNER CLOSELY WITH ICHCA, PARTICIPATING FQHCS, AND THE IDAHO DEPARTMENT OF HEALTH AND WELFARE (IDHW). COHORT 1 WILL MENTOR COHORT 2, FOSTERING PEER-TO-PEER LEARNING AND ENSURING LONG-TERM SUSTAINABILITY. POST-PROJECT, PARTICIPATING FQHCS WILL MAINTAIN QI ACTIVITIES, SUPPORTED BY DATA-SHARING AGREEMENTS AND ONGOING TECHNICAL ASSISTANCE FROM ICHCA. THIS INITIATIVE ALIGNS WITH CDC’S MISSION TO INCREASE CRC SCREENING RATES, ADDRESS HEALTH DISPARITIES, AND PROMOTE EVIDENCE-BASED PUBLIC HEALTH PRACTICES.