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Cheryl Modica,1 Joy H Lewis,2 R Curtis Bay3 1National Association of Community Health Centers, Bethesda, MD, USA; 2Department of Medicine and Public Health, A.T. Still University, School of Osteopathic Medicine, Mesa, AZ, USA; 3Department of Interdisciplinary Health Sciences, Arizona School of Health Sciences, A.T. Still University, Mesa, AZ, USACorrespondence: Cheryl Modica, National Association of Community Health Centers, Inc, 7501 Wisconsin Avenue, Suite 1100W, Bethesda, MD, 20814, USA, Tel +1 301 310 2250, Email cmodica@nachc.orgIntroduction: Health centers are community-based, patient directed primary care providers that offer accessible, high-quality primary care within medically underserved communities. Screening for cancer and managing complex chronic conditions such as diabetes, hypertension, obesity, and depression are vital services for the vulnerable populations seen by community health centers. Delivering care for complex chronic conditions and preventive services using virtual models that integrate self-care tools and technology is an important approach to increasing access for hard-to-reach patients served by health centers.Objective: This study aimed to explore the use of a virtual care model, applied using a systems approach and patient-driven tools and technology, on the performance of clinical and patient experience measures.Methods: A virtual care model, applied using a systems approach offered by the Value Transformation Framework (VTF), was combined with self-care tools and technology in twenty health centers across 17 states to drive improvement efforts. Changes in clinical measures and patient experience were compared.Results: A total of 385 patients were enrolled and 270 (70.1%) completed a baseline visit and at least four virtual visits during the six-month intervention period. Statistically significant improvements were seen in measures for HbA1c, systolic and diastolic blood pressure, and bodyweight. Among the 270 who completed the baseline and at least 4 virtual visits, the percentage up-to-date for colorectal cancer screening increased from 113/270 (41.9%) to 169/270 (62.6%) after six months, p< 0.001, a 20.7% increase. Patients completing the baseline visit and at least 4 virtual visits reported a 10.7% decrease in depression and increased satisfaction with virtual care visits compared to in-person visits (p< 0.001).Conclusion: Health centers applying the Value Transformation Framework’s organizing framework to the use of virtual care models together with patient self-care tools, technology, and education, had improvements in measures for chronic and preventive conditions and patient experience.Plain Language Summary: The Value Transformation Framework (VTF) was designed by the lead author to serve as an organizing framework for health center systems change and advancement toward the Quintuple Aim: improved health outcomes, improved patient experiences, improved staff experiences, reduced costs, and equity. When applied in the health care setting, the VTF translates research, evidence-based solutions, and promising practices into clear and practical steps that health centers can use to achieve value-driven care. In this paper, the authors report on results from a study where the VTF’s organizing approach was combined with evidence-based virtual care models supported by patient self-care tools, technology, and education with improvements seen in measures for colorectal cancer screening, hypertension control, diabetes control, weight, patient reported depression, and patient experience. The action steps taken by health centers participating in this quality improvement project can be replicated by other health centers.The impact of colon cancer, hypertension, diabetes, obesity, and depression, particularly among health center patients, is substantial. Identifying strategies to change health center systems in ways that improve performance is critically important. The authors demonstrated that implementing the VTF can provide health centers with a practical and actionable approach to health center systems change to achieve significant improvements in clinical measurements, patient-reported depression, and patient experience with care.Keywords: vulnerable populations, colorectal cancer screening, hemoglobin A1c, obesity, depression, patient experience

Kate Whelihan,1 Cheryl Modica,2 R Curtis Bay,3 Joy H Lewis1 1Department of Public Health, A.T. Still University of Health Sciences, School of Osteopathic Medicine in Arizona, Mesa, AZ, USA; 2Quality Center, National Association of Community Health Centers, Bethesda, MD, USA; 3Department of Interdisciplinary Health Sciences, A.T. Still University of Health Sciences, Arizona School of Health Sciences, Mesa, AZ, USACorrespondence: Joy H Lewis, 5850 E. Still Circle, Mesa, AZ, 85206, USA, Tel + 1 480 219 6000, Fax + 1 480 389 3661, Email JHLewis@atsu.eduIntroduction: Patient satisfaction and experience are important measures of overall quality of care. In 2017, the National Association of Community Health Centers (NACHC) launched an initiative to facilitate changes across organizational systems within Federally Qualified Health Centers (FQHCs) with the goal of improving value-driven care.Methods: NACHC worked with eight health centers, four in Georgia and four in Iowa, along with their state Primary Care Associations, to apply the Value Transformation Framework (VTF). This framework distills evidence-based practices into practical knowledge for goal-driven systems change. It provides actionable steps to help health centers reach value-driven goals of improved health outcomes, improved patient and staff experience, reduced costs, and improved equity (referred to as the Quintuple Aim goals). This paper reports on the patient and staff experience when applying VTF systems changes to improve colorectal cancer screening rates.Results: Patient and staff satisfaction and experience remained highly rated even after extensive organizational changes were implemented as part of this project. Implementation of a systems-approach to organizational change, through application of the VTF, did not negatively impact patient or staff experiences.Conclusion: Patient and staff satisfaction and experience were positive despite the application of the VTF and systems-wide organizational changes. These experience results were alongside improved cancer screening rates, as observed from full project results. Investigators are encouraged that the application of systems change using the VTF may result in the achievement of Quintuple Aim goals without disrupting the experience of patients and staff. Investigators recommend continued exploration of this transformation approach.Keywords: Quadruple Aim, Quintuple Aim, healthcare experience, cancer screening, primary care, prevention, community health

Cheryl Modica,1 Joy H Lewis,2 R Curtis Bay3 1National Association of Community Health Centers, Bethesda, MD, USA; 2Medicine and Public Health, SOMA Department of Public Health, School of Osteopathic Medicine in Arizona, A.T. Still University, Meza, AZ, USA; 3Department of Interdisciplinary Health Sciences, Arizona School of Health Sciences, A.T. Still University, Mesa, AZ, USACorrespondence: Cheryl ModicaNational Association of Community Health Centers, Inc., 7501 Wisconsin Avenue, Suite 1100W, Bethesda, MD, 20814, USATel +1 301 310 2250Email cmodica@nachc.orgIntroduction: Diabetes and pre-diabetes impact more than 114 million Americans. Federally qualified health centers (FQHCs) provide care to some of the most high-risk and underinsured individuals throughout the US, twenty-one percent of whom report being told they have diabetes, compared to 11% of the general adult population. It is widely agreed our health care system requires a transformation to effectively address diabetes and its complications.Objective: By applying the Value Transformation Framework (VTF) in health centers, the National Association of Community Health Centers (NACHC) aims to show improvements in diabetes control. This systematic strategy to transform the way health centers operate can lead to improvements in health outcomes, patient and staff experiences, costs, and equity (Quintuple Aim). Special attention is paid to the health centers’ infrastructure, people systems and care delivery systems.Methods: Evidence-based diabetes interventions, the learning community model, and the VTF were used together to drive system improvements and activate proven diabetes control practices within eight health centers. Multidisciplinary teams at select health centers in Georgia and Iowa, with their partner primary care associations, participated in this NACHC-led quality improvement project.Results: During the one-year intervention (January 2017–December 2017), the mean raw percentage of patients with HbA1c Poor Control decreased from 50.9% (range, 23.7– 70.4%) in January to 27.5% (range, 13.6– 37.4%) in December. This represents a relative improvement in diabetes control of 46%. The 1-year-intervention data also showed trends in the desired direction with statistically significant improvements related to the following interventions: a formal written clinical policy, standing orders, patient recall/outreach, performance data shared at the provider/team-level, and performance data shared at the site/organization level.Conclusion: A conceptual model focused on transforming health center systems, organized by the NACHC Value Transformation Framework and supported by a strong learning community, can lead to better diabetes control outcomes among patients seen at health centers.Keywords: vulnerable populations, hemoglobin A1c, quality improvement, health systems, interdisciplinary care

This paper reports the results of a numerical investigation aimed at assessing the effectiveness of the real-time control (RTC) of valves in reducing leakage in water supply networks. The investigation was carried out considering the head-driven simulation of a network under successive steady conditions. A literature bench-test case-study was used for the simulations enabling the comparison with other methodologies proposed by previous writers and based on the use of optimization algorithms. The performance of RTC was evaluated in terms of pressure and leakage reduction with respect to uncontrolled conditions in the network. Further elaborations showed the better flexibility of RTC, with respect to optimization algorithms, in adjusting valve regulation under variable daily water demand conditions. CE Database subject headings: Water distribution systems; Control systems; Computer programming; Water pressure; Leakage. Author keywords: Real time control (RTC); Logic controller; Valve. DOI: 10.1061/(ASCE)0733-9496(2010)136:1(138)

The various hydraulic and environmental problems related to the accumulation of solids have recently drawn increasingly attention to deposits in the management of sewer systems. Among the mechanical and hydraulic devices used for deposit removal, hydraulic flushing gates have proved to be a cost-effective solution and have been adopted in several sewer networks. This paper reports the results of an investigation on the scouring performance of flushing waves produced by hydraulic flushing gates. A numerical model based on the De Saint Venant-Exner equations in dimensionless form was validated by using data derived from laboratory experiments and was then utilized in this investigation. Simulations were carried out considering various values of the dimensionless parameters involved in the analysis, in order to obtain indications for the design and positioning of flushing devices in sewer channels. The problem of optimal flushing frequency was also investigated. DOI: 10.1061/(ASCE)0733-9429(2007)133:8(964) CE Database subject headings: Sewers; Sediment; Numerical models; Gates.