Our recipes are primers that will help you explore and implement care strategies to benefit your providers, patients, and practice. You can search for the available recipes by keywords, or browse using the filters below.

Improving Diabetes Care via Medical Assistants and Community Health Workers @ Northern California Community Health Centers

This project at a group of community health centers implemented a new medical assistant and community health worker-led diabetes care management program to study differential…

Innovators

  • Hector P. Rodriguez, MD, MPH
  • Mark W. Friedberg, MD
  • Arturo Vargas-Bustamante, PhD, MA, MPP
  • Xiao Chen, PhD
  • Ana E. Martinez, MPH
  • Dylan H. Roby, PhD

Remote Glucose Monitoring via Computerized Insulin Dosing @ Venice Clinic

A safety net clinic implemented a remote glucose monitoring intervention via computerized algorithms for insulin dose adjustments in order to to help clinicians make dosing…

Innovators

  • S. Joshua Davidson
  • Mayer B. Davidson, M.D.

Improving Dermatology Appointment Access via Telemedicine @ Massachusetts Community Health Centers

A collaborative of seven Massachusetts community health centers (CHCs) implemented a remote dermatology consult system in order to triage in-person referrals more effectively, improve in-person…

Innovators

  • Ranjani K. Paradise, PhD
  • Toni McGuire, RN, MPH
  • Carla Bettano

Tobacco Cessation via the “GetReady2Quit” (R2Q) SMS Program @ Massachusetts General Hospital Community Health Centers

This intervention sent proactive text messages with behavioral advice for primary care patients in an effort to support smoking cessation in all smokers, including those…

Innovators

  • Gina Kruse, MD MPH
  • Nancy A Rigotti, MD
  • Karen Chase, BA
  • Jennifer HK Kelley, RN, MSN

Individualized Care Delivery in Primary Care via Integrated Practice Units (IPUs) @ Cambridge Health Alliance Union Square Family Health Center

This intervention sought to adopt integrated practice units (IPUs) into a primary care practice using ‘pod’-based patient care with a multidisciplinary team, disease-oriented patient registries,…

Innovators

  • Nina Jain, MD, MBA, MSc
  • Toyin Okanlawon, MD, MPH
  • Kirsten Meisinger, MD, MHCDS
  • Thomas Feeley, MD

Employing Community Health Workers (CHWs) to Improve Population Health via the IMPaCT Model @ Penn Center for Community Health Workers

The IMPaCT (Individualized Management of Patient-Centered Targets) model is a standardized, scalable, evidence-based Community Health Worker (CHW) intervention proven to improve chronic disease control, quality…

Innovators

  • Shreya Kangovi, MD, MS
  • Scott Tornek, MBA
  • Olenga Anabui, MBA, MPH
  • Jill Feldstein, MPA
  • Tamala Carter

Improving Multicultural Depression Screening and Follow-up via Multilingual and Standardized Tools @ Harrisonburg Community Health Center

This quality improvement project aimed to improve depression management by offering both universal screening in several languages and additional tools for treatment decision-making and follow-up…

Innovators

  • Diana Jolles, PhD, CNM
  • Ann M. Schaeffer, DNP, CNM

Expanding Nursing Role via RN “Co-Visit” Model @ Clinica Family Health

A multi-site community health center implemented a care model expanding nurses’ roles in intake, documentation, and care plan communication, working alongside providers in “co-visits.”

Innovators

  • Karen Funk, MD, MPP
  • Malia Davis MSN, RN, ANP-C, NP

Reduction of Opioid Misuse in Primary Care via the Transforming Opioid Prescribing in Primary Care (TOPCARE) Program @ Boston Medical Center

Nurses provide electronic and in-person monitoring of high-risk primary care patients on long-term opioid prescriptions to ensure appropriate use and efficacy of medication.

Innovators

  • Jane Liebschutz, MD MPH
  • Christopher Shanahan, MD, MPH
  • Ronald Goldstein, MD

Improving Care Coordination via Johns Hopkins Community Health Partnership (J-CHiP) @ Johns Hopkins Medicine

Johns Hopkins Community Health Partnership (J-CHiP) is a three-pronged care coordination program with comprehensive community support for a cohort of high-risk patients, enhanced discharge procedures…