Population Health Collaborative

Constellation Consulting, LLC works in collaboration with the New Mexico Department of Health, Heart Disease & Stroke Prevention Program to convene the Population Health Collaborative (PHC). The PHC will meets throughout the year, and together addresses the six strategies developed by the CDC to reduce the burden of cardiovascular disease:

STRATEGY 1: Utilizing Electronic Health Records (EHR) to identify patients with undiagnosed or uncontrolled high blood pressure.

STRATEGY 2: Utilizing team-based care (non-physicians, such as pharmacists, nutritionists, nurse practitioners) to help patients manage high blood pressure and high cholesterol.

STRATEGY 3: Utilizing Community Health Workers (CHWs) to help control high blood pressure and high cholesterol.

STRATEGY 4: Facilitate use of self-measured blood pressure monitoring (SMBP) with clinical support.

STRATEGY 5: Systematic referral of patients with hypertension and high cholesterol to community programs/resources.

STRATEGY 6: Promote the adoption of Medication Therapy Management (MTM) between pharmacists and physicians for the purpose of managing high blood pressure, high blood cholesterol, and lifestyle modification.

PHC Meetings

The Spring 2022 Population Collaborative meeting was held online in March, 2022. The topic was Team-Based Care, and featured Best Practices in Team-Based Care and Team-Based Care Models, presented by Lindsey Haakenson, Program Manager, New Mexico Department of Health, Heart Disease & Stroke Prevention Program; Implementation of Team-Based Care in Chronic Care Management, presented by Bianca Kertson, MPH, Population Health Manager, La Clinica de Familia; and Community Health Workers in the Team-Based Care Model, presented by Jamie Slama, Training Coordinator/Certification Coordinator, New Mexico Office of Community Health Workers.

You can view a recording of this meeting here: https://youtu.be/dCE2lEQF0Bs

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The Winter 2022 Population Collaborative meeting was held online in January, 2022. The topic was Utilizing Electronic Health Records (EHR) to Identify Patients with Undiagnosed or Uncontrolled High Blood Pressure, and presented by Dr. David Larsen, Christus Health in Tyler, Texas. Dr. Larsen's presentation was followed by a panel discussion featuring Comagine Health, West Virginia University, and Syncronys discussing:

Connecting attendees with DOH and supporting contractors who can provide technical assistance with EHR support;
Health systems that currently use EHRs, and how to use EHRs to their full capacity;
What are the benefits of utilizing EHR in New Mexico (if your clinic is part of a larger system or not).

You can view a recording of this meeting here: https://youtu.be/oN2cWliGfmw

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The Spring 2021 Population Collaborative Meeting was held online in March, and focused on the role of Community Health Workers to help control high blood pressure and high cholesterol. This session also included information about training opportunities for CHWs, Community Health Representatives, and Promotoras. Our presenters included Jamie Slama, New Mexico Department of Health Office of Community Health Workers; Robin Hetzler, MCD; and Sandra Adondakis, New Mexico Community Health Workers Association.

You can view a recording of this meeting here: https://youtu.be/9k_slnbgTv8

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The Fall 2020 Population Health Collaborative Meeting was held online in November, and focused on facilitating the use of self-measured blood pressure monitoring with clinical support. Our presenters included Kim Sabo, Community Health Program Manager for Presbyterian Healthcare Services, and Sara Ukeiley, Self-Monitoring Blood Pressure Program Director for the YMCA of Central New Mexico.

You can view a recording of this meeting here: https://youtu.be/2CPPolVgJ8o

PHC 2021 Conference

The New Mexico Population Health Collaborative 2021 Conference was on June 10 and featured opportunities for those working in health systems and clinical settings to learn more about population health and strategies to reduce the burden of cardiovascular disease in New Mexico.

Remarks by Dr. Tracie Collins, Secretary of Health, New Mexico

Dr. Tracie Collins

Prior to her appointment as New Mexico Secretary of Health, Dr. Tracie C. Collins served as dean of the College of Population Health at the University of New Mexico, bolstering the state’s public health and pandemic-response leadership.

Collins has served in a variety of academic leadership roles, in addition to providing clinical care and conducting and overseeing clinical research. Prior to her tenure at the University of New Mexico, she served as chair of Preventive Medicine and Public Health at the University of Kansas, where she also served as the Kansas Health Foundation distinguished professor of public health and as a professor of internal medicine. At the University of Minnesota, she was co-leader of the Primary Care Research Consortium, co-director of the school’s Center for Health Equity Research Core, and an associate professor of medicine. In Texas, Collins served as an assistant professor of medicine at the Baylor College of Medicine and the director of the General Internal Medicine Consult Service of the Michael E. DeBakey V.A. Medical Center in Houston.

In addition to her clinical education and research in the United States, Collins has also lectured in Nepal and Kenya. She has produced nearly 80 scholarly publications over the course of her career, and she maintains a clinical practice as a vascular specialist. Collins earned a master of public health degree from the Harvard School of Public Health in Boston, Mass., where she also served as a clinical instructor, and a master of health care delivery science degree from Dartmouth College. She earned her doctor of medicine degree from the University of Oklahoma and her bachelor’s degree, in chemistry, from the University of Central Oklahoma.

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An Overview of Collective Impact, presented by Dr. Jennifer Gomez-Chavez, University of New Mexico Health Sciences Center, Office of Diversity, Equity & Inclusion

Dr. Jennifer Gomez-Chavez

Dr. Jennifer Gomez-Chavez has 30 years of experience working on issues of diversity and equity through her positions with the LULAC National Educational Service Center and the University of New Mexico (UNM) in Albuquerque. She holds a B.A. in Criminal Justice, a Master’s in Counseling, and a Doctorate in Educational Leadership. Currently, she serves as the Special Assistant to the Associate Vice Chancellor in the Office of Diversity, Equity, and Inclusion at UNM’s Health Sciences Center. In her role, Jennifer is the Executive Director of the Unidos Project, Central Region Director for ENLACE NM, and directs Collective Impact Initiatives. Jennifer is active in the community and has been recognized as a grassroots leader. She has received countless awards and recognitions for her service including the following: Inducted into the National LULAC Women’s Hall of Fame, Albuquerque Business First Women of Influence, Ohtli Mexican Government Award, UNM Presidential Luminaria Award for Inclusion, Access & Student Success, National Verizon Award – Latina Business Professional, New Mexico Hispano Round Table Legislative Walking the Talk Award, and the National MS Society induction into the Volunteer Advocacy Hall of Fame. Jennifer is a national speaker empowering individuals to use their voice for self-advocacy on educational and health issues.

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Pharmacists Role in Reducing the Burden of Cardiovascular Disease, presented by Stephanie Headrick, Duran Pharmacy

Stephanie Headrick, RPh

Stephanie is an ALMOST native New Mexican. She moved to New Mexico at the age of 5, and grew up in several different small towns in New Mexico, thus giving her a front-row view of health care, or lack thereof, in rural areas of our state.

She attended the University of New Mexico College of Pharmacy, and obtained her BS in pharmacy in 1992. While in pharmacy school, she answered a 2-inch ad for a pharmacy intern posted on the bulletin board at the pharmacy school, and this begin her journey at Duran Central Pharmacy. After 2 years as an intern, she graduated and took a position as a staff pharmacist at Duran’s. As of May, she has worked for Duran’s for 31 years. During these years, she has seen pharmacy go from dispensing prescriptions, to dispensing the knowledge that was taught in pharmacy school. The changes have been drastic, but exciting, and she is grateful to work at a pharmacy where forward thinking is encouraged. The programs that have been developed at Duran’s over the years have kept them at the forefront of pharmacy practice and given them the ability to do so much for their patients’ healthcare beyond dispensing. Wellness and nutrition are a passion for her, and she also spends time learning and educating her patients about the herbals, supplements, and homeopathics that have become a vital part of the pharmacy.

When not working in the pharmacy, she has raised 3 amazing kids, enjoys hanging out with her 2 -year old grandson, and loves escaping to the mountains of NM for a weekend of hiking.

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An Overview of Paths to Health and Utilizing Workshop Wizard, presented by Dana Bloomquist, CWA Strategic and Lynnzy McIntosh, Workshop Wizard

Dana Bloomquist

Dana Bloomquist is Senior Account Executive at CWA Strategic Planning, Paths to Health New Mexico marketing lead, and a Contractor to the New Mexico Department of Health. Dana joined CWA Strategic Communications in August 2001. Her responsibilities have included working with the Early Childhood Education and Care Department’s Family Infant Toddler (FIT) Program; the New Mexico Department of Health’s Breast and Cervical Cancer Early Detection, Comprehensive Cancer and Diabetes Prevention and Control Programs; and the Children, Youth and Families Department.

Lynnzy McIntosh

Lynnzy McIntosh has worked with integrating community-based programming and health care since 2008 when she joined the staff of the Consortium for Older Adult Wellness (COAW) in Colorado; eventually serving as Executive Director. Workshop Wizard was created in 2009 to meet the needs of developing referral systems with an entire spectrum of community based programs, including falls prevention, chronic disease self-management and diabetes prevention. Her friendship with the New Mexico Department of Health Diabetes Prevention and Control Program began in 2010 and expanded to include Workshop Wizard in 2015. Now, as Vice President of PAC Software, Inc. she continues as a contractor to the New Mexico Department of Health Diabetes Prevention and Control Program and brings her experience in health care referrals, implementation, and data management to programs across the country including the 16 states now using Workshop Wizard.

Resources

Check out these resources!

General Information & Reports

Community Health Workers, Community Health Represetatives, and Promotoras

The New Mexico Department of Health Office of Community Health Workers offers a variety of resources for CHWs, CHRs, and Promotoras. Please visit them online for more information: https://www.nmhealth.org/about/phd/pchb/ochw/

Videos

National Association of Community Health Centers (NACHC): How to Use Your Home BP Monitor is a brief video explaining the value of SMBP to patients and the key steps they should follow to take an accurate blood pressure measurement outside of the clinical office.
https://www.youtube.com/watch?v=0tGyRJxbYpQ (English)
https://www.youtube.com/watch?v=AQLDGAwQvzE (Spanish)

Resources to Find a Home Blood Pressure Monitor

AMA SMBP cuff selection
https://www.ama-assn.org/system/files/2020-05/smbp-cuff-selection.pdf
US Blood Pressure Validated Device Listing (VDLTM)
https://www.validatebp.org/

Select Case Studies

National Association of Community Health Centers (NACHC): Self-measurement: How patients and care teams are bringing blood pressure to control; A video describing the experience of three community health centers in providing SMBP and the stories of their patients who used SMBP to improve their health.
https://www.youtube.com/watch?v=XGO-I59UMDg (full video)
https://youtu.be/VNQQ8ranUZo (D’Angelo’s Story)
https://youtu.be/malq4KnCESY (Natalia’s Story)

Hypertension Control Champions Success Stories - A webpage with SMBP success stories from the Million Hearts® Hypertension Control Champions, those clinicians, practices, and/or health systems recognized by CDC for achieving exemplar hypertension control rates.
https://millionhearts.hhs.gov/partners-progress/champions/success_stories.html

Discussion Forum

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Population Health Collaborative, stakeholders, and interested community members can utilize our Discussion Forum to post topics, hold online discussions, and network with each other.

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PHC Members

Our Population Health Collaborative members include: