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Spring 2016


EDITORIAL How are we affecting the community we serve

Chicago is a world class city that carries with it an impressive history of population health based initiatives. Declines in morbidity and mortality during the 20th century resulted in large part from effective health promotion and disease prevention programs. With the passage of the Affordable Care Act in 2010 there is increased emphasis on health systems developing models of care that improve quality of care, outcomes and efficiency. The University of Illinois Hospital and Health Sciences System (UI Health) is a patient centered organization. Providing safe, high-quality and cost-effective care for our patients is our foremost responsibility. The care of our patients and their families will always be at the heart of our mission. The PHSP was developed in 2011 to provide enterprise level oversight for the development, testing and implementation of care models that achieve the triple aim of improved quality, better outcomes and lower cost. 1-855-I-WHEEZE



Health Sciences Program Overview

23 Collaborating Partners

24 Program Staff



hile UI Health serves the needs of people in the city of Chicago, the state of Illinois, various regions of the United States and worldwide, our health system's primary service area is defined by 24 community areas in the middle and west side of Chicago. The UI Health system includes a 495 bed hospital and 13 Mile Square Health Centers located throughout Chicago.


Communities Served by the University of Illinois Hospital & Health Sciences System



Population Health Sciences Program Projects

National Awards Facilitated by the Population Health Sciences VPHA innovative healthcare strategy awards ... this resulted in xxx letters



Total Award

Project Period

PATient Navigator to rEduce Readmissions (PArTNER) PI: Jerry Krishnan

Patient-Centered Outcomes Research Institute (PCORI)



Bringing Care to Patients: A Patient-Centered Medical Home for Kidney Disease* PI: Denise Hynes, UIC College of Nursing




Comparative effectiveness of a PEer-Led O2 Infoline for patients and Caregivers (PELICAN) PI: Jerry Krishnan




Chicago Area Patient Centered Outcomes Research Network (CAPriCORN) PI: Multi PI (Contact PI: Terry Mazany, Chicago Community Trust)




The Coordinated Healthcare Interventions for Childhood Asthma Gaps in Outcomes (CHICAGO) Trial PI: Jerry Krishnan




Coordination of Healthcare for Complex Kids (CHECK)* PI: Ben Van Voorhees, UIC Department of Pediatrics

CMS – Center for Medicare and Medicaid Innovation






Achieving Patient-Centered Care and Optimized Heath In Care Transitions by Evaluating the Value of Experience (Project ACHIEVE) PI: Mark Williams, University of Kentucky Coordinated Healthcare Interventions for Childhood Asthma Gaps in Outcomes II (CHICAGO II) PI: Kate McMahon TOTAL


National Institutes of Health





A Primer


Managed Care vs. Population Health Management


Determination of Health Population Resources and expertise within health care systems.

Resources and expertise typically external to health systems. Require Universitylevel engagement to identify internal and external partners.


Population health is about right sizing care to the individual needs to promote wellness and health.


Example of one high-risk, high-cost patient Limited socioeconomic resources contribute to high readmission rates at minority serving institutions (MSIs). A better understanding of patient- level factors and need for patient navigators could inform approaches to enhance care transitions tailored to these vulnerable patient populations. This is the story of a 59 year old woman who was admitted to UI Health six times over the course of one year for treatment of a congestive heart failure exacerbation. She had a history of missing follow up appointments and non-adherence to diet and medications documented in her electronic health record.

Underlying Problems Following intervention by a Patient Navigator, the patient was found to have drug addiction initiated by significant grief following the loss of her spouse after 21 years of marriage. She had no social support, no telephone due to lack of funds and no transportation to attend her medical appointments.

Source: Ursan, I., et. al. Engaging Patients and Caregivers to Design Transitional Care Management Services at a Minority Serving Institution. Journal of Health Care for the Poor and Underserved. 27(2016). PArTNER, #IH-11-12-4365



Networks with limited geographic coverage or services or availability are insufficient to manage total costs of care

Develop partnerships to provide on-demand, high-quality, comprehensive, and accessible care

Shift from use of retrospective data to individualized care plans in real time

Integration of data networks that links operational and clinical data across platforms within organization and with external partners

Credible leader who merges data analytics with clinical care

Individuals who work at top-of-license

Service oriented, works as team

Establish preferred partner network with patient and provider incentives to reduce outof-network exposure

Align compensation (can exceed 100%) to meeting enterprise goals: quality, outcomes, cost

Map services to needs of population


Four Key Elements to Population Health Management

- Clinical and non-clinical - Reach at-risk populations •

Engage patients in own care and health - Integrate patient preferences into care - Peer coaches, Community health workers/navigators, incentives 11

Population Health Sciences Program Projects UICAN - Place Holder

Warfarin Pharmacogenetics Service Funding: UI Health Description: In August 2012, UI Health became the first hospital in the nation to implement a warfarin pharmacogenetics service to provide genotype-guided warfarin dosing and anticoagulation assistance for all patients newly starting warfarin while hospitalized at UI Health. The goal was to reduce time to therapeutic INR and decrease the number of patients with excessively high warfarin levels by better estimating warfarin dose through genetic testing. The new genetic testing program, part of UI Health's Personalized Medicine Program showed reduced complications and improved patient safety — with significant cost savings — over its first 16 months in operation. Read more about the implementation of the program: Nutescu EA, Drozda K, Bress AP, Galanter WL, Stevenson J, Stamos TD, Desai AA, Duarte JD, Gordeuk V, Peace D, Kadkol SS, Dodge C, Saraf S, Garofalo J, Krishnan JA, Garcia JG, Cavallari LH. Feasibility of implementing a comprehensive warfarin pharmacogenetics service. Pharmacotherapy. 2013 Nov;33(11).



UNiversity of Illinois Survey On Neighborhood Health (UNISON) Funding: UI Health

Description: An in-person community health needs assessment of 1400 individuals that live in 24 community areas served by UI Health. This scientifically rigorous examination collects patientreported information about health behaviors, health care access and utilization, prevalence of disease conditions, quality of life indicators, and knowledge of the Affordable Care Act and basic biometric screenings. The goal is to understand the health needs of the diverse community served by the UI Health System and to use this information to improve health care for those who need it the most.

PATient Navigator to rEduce Readmissions (PArTNER) Funding: PCORI contract # IH-12-11-4365 Award: $1,973,706 Description: The study focuses on developing and testing a program that combines a community health worker (lay patient advocate, acting as a “Patient Navigator�) and a peer-led telephone support line to increase social support, improve self-efficacy and postdischarge acute care use. The goals of PArTNER are: 1. Provide a patient-centered intervention tailored to the needs of the patients and caregivers we serve, with community health workers and telephone-based peer support. 2. Improve the patient and caregiver experience during transitions out of the hospital 3. Increase social support, reduce anxiety, and reduce avoidable hospital readmissions. Read more about the program: Ursan ID, Krishnan JA, Pickard AS, Calhoun E, DiDomenico R, PrietoCenturion V, Sullivan JB, Valentino L, Williams MV, Joo M. Engaging Patients and Caregivers to Design a Transitional Care Managment Service at a Minority Serving Institution. Journal of Health Care for the Poor and Underserved. 2016; 27.



Comparative effectiveness of a PEer-Led O2 Infoline for patients and Caregivers (PELICAn) Funding: PCORI contract # CE-1304-6490 Award: $1,981,913

Description: We have developed a broad-based collaboration with patients/caregivers, advocacy groups, and a national O2 supplier with the goals of: (1) engaging patients and caregivers to identify gaps in knowledge, self-management skills; and (2) testing effectiveness of PELICAN as a proactive intervention (peer coaches contact and deliver intervention) vs. reactive intervention (peer coaches deliver intervention when contacted) vs. usual care. The goal is to test whether a patient-centered PEer-Led o2 Info-line for patients and CAregivers (PELICAn) will increase adherence and improve health.

Read more about the program design: Holm KE, Casaburi R, Cerreta S, Gussin HA, Husbands J, Porszasz J, Prieto-Centurion V, Sandhaus RA, Sullivan JL, Walsh LJ, Krishna JA. Patient Involvement in the Design of a PatientCentered Clinical Trial to Promote Adherence to Supplemental Oxygen Therapy in COPD. Patient. 2015.

Emergency Patient Interdisciplinary Care for Frequent ER Visitors (EPIC) Funding: UI Health Description: This innovative initiative developed individualized health management programs for Medicaid patients who were frequent visitors to the emergency room. The EPIC team worked with patients to create a 1-3 month transitional care program that helped patients learn what to do to manage their health, which providers they needed to see and how often, and other resources were available. The goal was to enhance quality of care, improve health outcomes, and lower Illinois Medicaid costs by reducing ER visits and hospitalizations. The EPIC project has evolved into the teams that will support patients in the Clinical Decision Unit (CDU) at UI Hospital.


The Coordinated Healthcare Interventions for Childhood Asthma Gaps in Outcomes (CHICAGO) Trial Funding: PCORI contract # AS-1307-05420 Award: $3,999,823 Description: The CHICAGO Trial is a collaborative effort between 13 Chicago based institutions, including the University of Illinois Hospital & Sciences System, Sinai Health System, Rush University Medical Center, Lurie Children’s Hospital, University of Chicago, Northwestern University, Chicago Department of Public Health, Respiratory Health Association, Chicago Asthma Consortium, NorthShore University Health System, and the Illinois Institute of Technology. This broad-based collaborative, including caregivers, patient advocacy groups, public health officers, and patient-centered outcomes researchers is dedicated to eliminating asthma health disparities. Drawing on collaborations that span nearly two decades, we propose studies testing both provider- and patient-level interventions to improve clinically meaningful outcomes in a minority pediatric ED population with uncontrolled asthma. The goal is to improve outcomes in minority children with uncontrolled asthma, through provider and patient-level interventions. Read more about the project: Erwin K, Martin MA, Flippin T, Norell S, Shadlyn A, Yang J, Falco P, Rivera J, Ignoffo S, Kumar R, Margellos-Anast H, McDermott M, McMahon K, Mosnaim G, Nyenhuis S, Press V, Ramsay J, Soyemi K, Thompson TM, Krishnan JA. Methods and outcomes of engaging stakeholders to design a comparative effectiveness trial in children with uncontrolled asthma. J Comp Eff Res. 2016 Jan;5(1). Chicago Area Patient Centered Outcomes Research Network (CAPriCORN) Funding: PCORI contract # CDRN-1306-04737 Award: $6,992,682. Description: This project is intended to leverage health system clinical and administrative data at UI Health to support stateof-the-art patient-centered outcomes research (PCOR) in 100 million people in the U.S. CAPriCORN is a collaboration with academic medical centers in Chicago, the Chicago Community Trust (prime), the Illinois Medical District, payers, and multiple organizations in Chicago and elsewhere in the U.S. Read more about the project: Kho AN, Hynes DM, Goel S, Solomonides AE, Price R, Hota B, Sims SA, Bahroos N, Angulo F, Trick WE, Tarlov E, Rachman FD, Hamilton A, Kaleba EO, Badlani S, Volchenboum SL, Silverstein JC, Tobin JN, Schwartz MA, Levine D, Wong JB, Kennedy RH, Krishnan JA, Meltzer DO, Collins JM, Mazany T, CAPriCORN Team. CAPriCORN: Chicago Area Patient-Centered Outcomes Research Network. J Am Med Inform Assoc. 2014 Jul-Aug;21(4). 15

PHSP PROJECTS Coordination of Healthcare for Complex Kids (CHECK) Funding: Centers for Medicare and Medicaid Services – Center for Medicare and Medicaid Innovation (Van Voorhees, Department of Pediatrics, Principal Investigator). Award: $19,581,403 Description: A previous version of this project received a proposal development award from UI Health Population Health Sciences Program. It was then submitted to CMS-CMMI and funded. This new medical care model is designed to manage the healthcare of over 6,000 children in Cook County with complex medical issues like asthma, depression, diabetes and sickle cell. CHECK uses a "medical neighborhood" model where a primary care provider acts as the main coordinator of care for the patient. Employing a holistic approach and a focus on preemptive care, CHECK connects patients and families to primary care doctors, specialists, mental health clinicians and other health professionals to better manage the delivery of care with the goal of reducing hospitalizations, ER visits and missed school days for children with these chronic conditions. CHECK will deliver care through a network of 40 primary care sites around Chicago that includes UI Health and the Mile Square Health Centers as well as other Federally Qualified Health Centers in the city. The CHECK program along with UI Health Plus Managed Medicaid program provides new models of care for meeting the healthcare needs of the communities we serve in the midst of the changing environment of healthcare. Bringing Care to Patients: A Patient-Centered Medical Home for Kidney Disease Funding: PCORI contract # IH-12-11-5420 Award: $2,093,521 Description: A previous version of this project received a proposal development award from UI Health Population Health Sciences. It was then submitted to the Patient-Centered Outcomes Research Institute and awarded. The purpose of this project is to compare a patient-centered medical home model of care with the usual care of end-stage renal disease patients and their caregivers. Model is to be implemented at the UI Health dialysis center and a local Fresenius Medical Care dialysis center. Patients receiving dialysis at participating centers will receive an initial comprehensive care visit followed by ongoing care from a multispecialty provider team during the patients’ regularly scheduled dialysis visits. Each patient’s care team will include a kidney doctor, a primary care doctor, an advanced practice nurse, a dialysis nurse, a dietician, a pharmacist, a social worker, and a health promoter. Read more about the project: Porter AC, Fitzgibbon ML, Fischer MJ, Gallardo R, Berbaum ML, Lash JP, Castillo S, Schiffer L, Sharp LK, Tulley J, Arruda JA, Hynes DM. Rationale and design of a patient-centered medical home intervention for patients with end-stage renal disease on hemodialysis. Contemp Clin Trials. 2015. 16

Chicago II - Place Holder

Achieving Patient-Centered Care and Optimized Heath In Care Transitions by Evaluating the Value of Experience (Project ACHIEVE) Funding: PCORI contract # ETC-1403-14049 Award: $14,996,291 Description: The University of Illinois Hospital & Health Sciences System is part of a collaboration of nationally recognized leaders in health care and research methods, partnering with patients and caregivers to evaluate the effectiveness of current efforts at improving care transitions and develop recommendations on best practices for patient-centered care transitions and guidance for spreading them across the U.S. This partnership has been funded by a 3-year award from PCORI. The UI Health team is leading the stakeholder engagement effort for the project.


Present --> Future


2011-2015: Neuropsychiatric Institute Building #950, NPI, South Tower, 2nd floor

April 2016: Mile Square Health Center Building #929, MSHC, 3rd floor



2014, 1200 sq ft. space provided to PHSP in NPI-N

March 2012, 2093 sq ft. space occupied by PHS/BCC

March 2012, 2542 sq ft. space yielded to CCTS/CRC

With the temporary space allocation, we were able to meet a fraction of the program's needs. On 2012, 2542 sq ft were allocated for PHS & BCC's use. The same year we expanded to an additional 2093 sq ft; and by the end of 2014 we added an additional 1200 sq ft.


Sept. 2011, 4635 sq ft. Space allocated to PHS/BCC (cost for renovation, furniture, laboratory, electronics, $433,575)


In 2011 temporary space was offered to the Population Health Sciences Program in the South tower of the Neuropsychiatric Institute (NPI) building. This was shared space with the Clinical Research Center. In 2014 the College of Medicine Dean and the Department of Neurosurgery graciously offered temporary expansion space in the North tower of the NPI building to meet the needs of a growing PHS Program. Though this space helped the program, it still left us forty percent short on space for our fulltime staff.

Population Health Sciences & BCC Footprint


April 2016

Mile Square Health Center 1220 S. Wood Street, 3rd floor Raw sq. footage: 10,700 sq ft (incl. egress, corridors, elevators)

This new space in the MS clinic includes clinic rooms, phlebotomy, laboratory, sputum induction rooms, clinic and administrative storage space and an administrative office suite to fit program staffing needs.

PARTNERSHIPS The healthcare market place is increasingly focused on achieving the “triple aim� of higher quality, better outcomes, and lower cost following the passage of the Affordable Care Act in 2010. UIC includes a full complement of health sciences colleges (Applied Health Science, Dentistry, Medicine, Nursing, Pharmacy, School of Public Health, Social Work), in addition to colleges in Architecture, Design, and the Arts; Business Administration; Education; Engineering; Liberal Arts and Sciences; and Urban Planning and Public Affairs. At UI Health, we are engaging physicians, nurses, other clinicians, and staff in cost and quality improvement efforts, empowering patients in health promotion and wellness campaigns, and expanding the use of interprofessional models of care to increase access, convenience, and affordability of care. 21

VCHA PHS Bridges + Engages Professional Groups to Improve Care



VCHA PHS's Project Partners Span in the US

Staff O

ur team is comprised of dedicated professionals who are committed to the patients they serve. Our coordinators, nurses, doctors, scientists and research personnel come from diverse backgrounds ranging from dentistry, to management information systems, to law, nursing, and much more! We enjoy the diversity our program brings and believe it makes us stronger and better able to serve our population.

Jenna Allen Undergraduate Research Assistant College of Applied Health Sciences

Yasmin Arroyo Office Coordinator

Nina E. Bracken, APN Clinical & Reasearch Program Manager

Michael Bradford Administrative Assistant

Jennifer Buenrostro Clinical Research Coordinator

Crystal Cannon Patient Recruiter

Valentin Prieto-Centurion, MD Pulmonary Fellow

David de la Torre Dorado Clinical Research Coordinator

Julie DeLisa, MA Project Manager

Jessica Dudley Graduate Research Assistant College of Nursing

Dameka Edwards Community Health Worker

Vanessa Gonzalez Alex Frye Project Manager Graduate Research Assistant College of Liberal Arts & Sciences

Eugenia Haddad Uzma Kazmi Undergraduate Research Clinical research Coordinator Assistant College of Liberal Arts & Sciences


Amelia Mutso, PhD Project Manager

Clarissa Najera Undergraduate Research Assistant College of Liberal Arts & Sciences

Mounica Sireni Graduate Research Assistant Graduate School of Business

RoShwanda Thompson Community Health Worker

Jerry Krishnan, MD, PhD Associate Vice President, Population Health Sciences

M. Lourdes Norwick, RN Research Nurse

Emma Villareal Community Health Worker

Maciel Grabarek Data Manager Analyst

Kyle Maggio Graduate Research Assistant College of Nursing

Melissa Morales Perez Clinical Research Coordinator

Vidya Visvabharaty Graduate Research Assistant School of Public Health

Helene Gussin, PhD Scientific Manager

Victoria Morken Clinical Research Coordinator

Jenny Scully, MD Es Design Strategist

Farhan Zaidi, MD Pulmonary Fellow


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