Chronic Disease Collaborative

For Philadelphia Health Centers

Working to reduce health disparities in morbidity and mortality due to heart disease and stroke

About the Chronic Disease Collaborative

With a focus on hypertension and high cholesterol, this program supports seven Philadelphia Federally Qualified Health Centers (FQHCs) in implementing evidence-based best practices. The health centers are joined in a learning collaborative by three major health systems to promote information sharing. Over 100,000 adult patients receive care from health centers participating in this program, which is supported by the Philadelphia Department of Public Health with funding from the Centers for Disease Control and Prevention.

Strategies

Participating health centers are encouraged to improve patient care in a variety of ways, including engaging teams (including behavioral health consultants, pharmacists and medical assistants) in hypertension management, implementing data systems, monitoring quality measures, and addressing patients’ social needs such as food insecurity and social isolation.

Project examples

  •  Assess, develop, and implement a practice approach for team-based care

  • Implement population health tools like dashboards to motivate provider change

  • Motivational Interviewing training for care team members

  • Engage pharmacists to work with patients on medication adherence

For More Information Contact:

Suzanne Cohen, Senior Director of Population Health
215-567-8001 ext. 3026