Evaluating the Impact of an Equity Focused Dashboard and Clinical Support

"Providers will be given access to an equity dashboard that displays their practice's performance on ambulatory quality metrics stratified by race and language.~Population health coordinators (PHCs) will lead equity huddles with providers to review list of patients who are not at goal for their hypertension control and meet the inclusion criteria. Providers will formulate a follow up plan for each patient that the PHCs will help implement. For example, PHCs may contact patient via the online patient portal or phone to obtain recent home blood pressure readings, facilitate scheduling of follow up visits, etc.~In addition, patients may be referred to the community health worker (CHW) hypertension management program. Patients will work with the CHW for 3-6 months. During this time the CHW will focus their efforts on patient education/coaching, remote blood pressure monitoring, addressing psychosocial and socioeconomic barriers to care and care coordination."

"Providers will be given access to an equity dashboard that displays their practice's performance on ambulatory quality metrics stratified by race and language.~In addition, population health coordinators (PHCs) will lead disparities focused huddles with providers. During the huddle, they will review list of patients who are not at goal for their hypertension control and meet the inclusion criteria. Providers will then formulate a follow up plan for each patient that the Population Health Coordinators will help implement. For example, PHCs may contact patient via the online patient portal or phone to obtain recent home blood pressure readings, facilitate scheduling of follow up visits, etc."