Health Care News, Social Determinants of Health, Uncategorized

New Innovation Blog Series: Leading Change

Welcome to NACHC’s Innovation Blog Series! Throughout the year, this series will feature innovation topics, case studies, innovative NACHC programs and more. This week, NACHC’s Innovation Center team interviewed NACHC’s Quality Center team about the Leading Change: Transforming At-Home Care pilot project. The interview below features a rich conversation with Cheryl Modica, Director of the Quality Center, along with the Quality Center’s Lizzie Utset, Manager, and Addison Gwinner, Specialist.

Leading Change – Transforming At-Home Care

At the start of the pandemic, when the need for robust virtual care was at an all-time high, the Quality Center launched the Leading Change project. The work has resulted in many lessons learned that your health center, Primary Care Association (PCA), or Health Center Controlled Network (HCCN) can use to implement patient self-monitoring kits and telehealth. This program truly shows what can be achieved when taking a demanding situation, such as COVID-19, and transforming it into an opportunity for innovation.

Q: Before going any further, can you explain a bit about the program?

Leading Change was a unique opportunity to be able to work together with the field in offering groundbreaking approaches and novel strategies for delivering virtual care at home.

This project implemented the concept of Patient Care Kits to aid in the transition to virtual care. The Kits contained colorectal cancer screening tests, patient monitored blood pressure cuffs, and tests to measure blood sugar. Health centers distributed the Kits to patients with diabetes in the pilot to support their at-home care virtual visits.

These tools supported at-home virtual care visits by utilizing comprehensive, whole-person care by looking across a number of chronic conditions and preventative screenings such as cancer screening, diabetes control, and hypertension assessment and monitoring.  A scale and a thermometer were also included in the Kits to support messaging around nutrition and exercise and allow patients to monitor their temperature for potential early signs of COVID-19 infection.

Through a competitive national process, NACHC selected 20 health centers representing 17 states. Each health center engaged up to 20 patients for a total of 385 patients.

Q: What are some key findings you had throughout this process?

  • Receptivity. Patients were incredibly receptive to the project, and they appreciated their care teams for meeting them where they were. There were a variety of strategies used to get these tools in the hands of patients and to guide them through the process of learning to use them. Health centers were flexible and took into consideration that patients’ general health, comfort with technology, and access to technology varied significantly.
  • Overcoming the technological barrier. Before the pandemic, many of the health centers experienced barriers when diving into virtual care, such as patients not being able to access the technology or use it. During the pilot, health centers had to be innovative and creative to overcome barriers to virtual care. Some provided support and instruction on the different technologies, used family members or friends for help, or conducted in-person training.
  • Patient outreach. We received feedback that prior to the project, some health centers had trouble engaging with patients that went on to take part in the project. However, by the end, many were able to manage their health through the Kits.
  • Patient empowerment. The Kits encouraged patients to take responsibility for their health, and we saw that they gained from measuring and reporting their vitals. While patients were asked to provide four weeks of self-measured vitals, some patients provided as many as 38 weeks of data. For these patients, it became part of their daily wellness routine and part of their own view of self-care. This shows how a program like this can be used to empower patients with chronic illnesses to take an active role in their care.

Q: Leading Change is just one part of the Quality Center’s work. What is the larger foundation behind this pilot?

The Value Transformation Framework (VTF) drives the work of the Quality Center. The VTF is a conceptual model that guides health centers through systems change. In this case, we applied it to improving virtual care at home, while focusing on cancer screening, diabetes control, and hypertension control. But the VTF is a way for health centers to organize work and action steps that about how move the organization towards value transformation, as defined by the Quintuple Aim Goals of improved health outcomes, improved patient and staff experiences, reduced costs, and improved equity.

Q: How do you get started implementing a Leading Change pilot at your health center?

NACHC’s Quality Center developed a suite of tools that can be found on the Leading Change webpage.

These materials also contain a series of appendices that include patient educational materials, patient logs, press releases and other tools in English, Karen, Lao, Vietnamese, and Spanish.

Q: What can we expect from the next iteration of a Leading Change program?

Leading Change was created in the context of responding to a pandemic, leading innovation, and reinventing virtual care. We are taking those themes, lessons, and strategies and deploying them into two new projects. The first project focuses on diabetes management and prevention. We are launching a Virtual National Diabetes Prevention Program together with our PCA and HCCN partners. The program focuses on individuals with diabetes as well as family members or significant others who either have diabetes or are at risk of diabetes.

The other piece is our work to secure donated colorectal cancer screening at-home kits that can be distributed to health centers to build on the lessons learned from Leading Change.

Q: How can health centers, PCAs and HCCNs be kept on the loop about upcoming opportunities?

Just as the VTF is the foundational model for the work that we do, the Elevate Learning Forum is our landmark initiative. It is the point of entry for all the Quality Center’s programs. Elevate is a national forum for health centers, PCAs, HCCNs, and other partners modeled around the VTF curriculum.

Registration is free and open at This registration will grant access to upcoming national learning forums and peer-to-peer Connect sessions, the grab-and-go resources housed on the online learning platform, and exclusive scholarship opportunities.

As we saw, Leading Change transformed a challenge into opportunity. We would love to hear from you! How has your health center, PCA, or HCCN transformed a challenge into opportunity?

Leave your answers in the comments below!