Project of the Year, Population Health: Community Family Practice, San Antonio

Bridge of Excellence program helps identify, target at-risk patients.


This Bridge of Excellence Program provider issued aggregate data to help identify and target at-risk diabetes, cardiac and hypertension patients through Lean Sigma Six methodology.

Even though the program requires certain clinical measure outcomes, Community Family Practice was able to expand those outcomes, such as frequency of measure attainment at each patient visit and nonvisit. The organization said that the data helped it save resources and time, and analytics gave the facility the ability to see the full scope of cost, utility and real-time hospital analytics reported.

Representatives from Community Family Practice say their success from the Bridge of Excellence Program was more than just data sharing. The model also worked through the incorporation of emails, forums, chats and webinars to help the practice hit its goals.

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