Implementation of a Patient Engagement Program in a Federally Qualified Health Center

Purpose The purpose of this project is implementation of a patient engagement program at a Federally Qualified Health Center (FQHC) clinic. This program intends to increase patient self-management of disease without increasing tasks of the clinic staff. Background FQHCs have limited resources and staff; their populations are marginalized and transient. The care gap is between the clinic’s resources and patient self-management of disease, specifically hypertension. Evidence shows that personalized coaching of patients aids them with disease self-management. Methodology This project delivers personalized coaching via weekly brief phone calls from two assigned nurses to patients, without disrupting clinic duties. Calls involve coaching, patient-reported daily blood pressure, medication adherence encouragement, and answer questions, with encounters documented in the electronic medical record (EMR). Weekly team meetings review Plan Do Study Act (PDSA) cycles and adjust the program accordingly. Results After 11 weeks of the patient engagement program, nurses deemed it unsustainable despite high patient engagement, citing laborious phone calls requiring multiple weekly attempts. Patients reported feeling more connected to the clinic and confident in disease management. FQHCs face funding challenges from federal cutbacks and budget constraints, exacerbating staff strain through multiple roles, turnover-induced shortages, and new hire training. Implications Personalized coaching is an effective patient engagement tool. However, implementation of programs can be challenging. Weekly phone calls, although well received by the participants in the program, proved to be too laborious for clinic staff. Future programs may be better implemented by texting from the EMR. However, that requires software updates and associated costs.