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Community Health Care Association of New York State


DRVS Visit Planning Implementation Propels New York Community

Health Center Practice Transformation

According to a study shared in Population Health Management1, team-based care stood out as the most critical method used to transform practices to provide patient-centered care successfully. Though the concept seems simple enough, innovative team-based care models require a level of change in clinical roles and responsibilities, process adjustments, and additional training in the use of Health IT that can sometimes be a daunting endeavor for health center leaders and staff.

For the Community Health Center Association of New York State (CHCANYS), the opportunity arose to implement DRVS Visit Planning in twelve community health centers while working on a New York State Cancer Screening Registry project – a five year Centers for Disease Control and Prevention (CDC) – funded demonstration project to advance practice transformation. The CHCANYS team was excited that they could take advantage of support components built for the CDC grant to help the centers meet the objectives of the two-year transformation initiative.

New York state has 72 Federally Qualified Health Centers (FQHCs) representing 750 practice sites serving 2.2 million patients. 100% of the centers are Patient Center Medical Home (PCMH) recognized with six on the “succeed” track in the 2017 NYS PCMH program. The twelve centers in the initiative were chosen mostly due to their work on team-based care as part of the CDC grant. The objectives of the initiative furthered their work by:

  • Understanding the change management phases needed for care team transformation,
  • Illustrating ways care team transformation can help practices achieve the Quadruple AIM, and
  • Realizing the benefits of implementing visit planning in a health center.

To support the health centers, CHCANYS Quality and Technology Initiatives Practice Transformation Support Services (QTI) and the Center for Primary Care Informatics (CPCI) were imperative for success.

The QTI team supports FQHCs with value-based healthcare and payment arrangements, drives operational excellence in the use of Health IT, and promotes integration with Medical Neighborhood and advanced primary care models. Dr. Diane Ferran, Vice President of Clinical Affairs and Performance Improvement at CHCANYS oversees the services and the team of coaches that provide training and consulting to the health centers.


The CPCI is the clinically integrated data warehouse and population health system built on Azara DRVS that helps CHCANYS and the health centers extract EHR data, view performance dashboards, calculate performance metrics and provide clinical workflow tools such as registries and visit planning.

Working with Azara, CHCANYS developed a 12-week change management curriculum for centers to hard-wire data use at the point of care. The plan included the use of the DRVS Visit Planning Report and project structure for each center.

The DRVS Visit Planning Report is an electronic list of essential data for patients with upcoming appointments. It replaces the work MAs and LPNs do manually with EHR data and configurable care alerts. The report displays only relevant and actionable items to help care teams prepare for visits and shows all patients with appointments and alerts in one single list ideal for care team huddles.  See video example of how Visit Planning works!

The structure of the program includes instructions on how to create:

  • Goals and Objectives
  • Expected Results
  • Team Members and Roles
  • Measures and Targets
  • Standing Actions
  • Documentation
  • Team Huddle

CHCANYS health centers realized significant quality improvements from 5 to 47% on many quality measures. Evaluations were performed across ten centers, within individual centers, and within teams. Below are examples of improvements:


“The collaboration with Azara’s VP of Clinical Transformation, Heather Budd, and the insights we gained from our coaches helped us aim our arrows at the right health centers ready to transform their practices,” states Lisa Perry, VP of Health IT, CHCANYS.

Practices improved data capture, clinical workflows and processes and implemented daily huddles for logistics, care management, and patient resource planning. Team-based care is flourishing, and CHCANYS health centers are achieving the Quadruple AIM by improving employee satisfaction through the reduction of provider burden and the empowerment of the support staff. They have also bettered patient outcomes and experience and met and exceeded measure targets. The prepared curriculum and documentation used at the 12 centers enabled other health centers in the state to easily adopt visit planning and advance team-based care at their locations.