Su Clinica

Su Clinica Familiar, Inc. Strongly believes that the true wealth of a community can be judged by the health of its population. We go beyond the traditional doctors office by offering a wide variety of community programs aimed at increasing the health status of the entire community. We believe that healthy citizens perform better in our schools, contribute more to our economy and establish a strong foundation for the community's viability. In the past year Su Clinica served 30,185 patients, of which 11,395 were uninsured. Su Clinica's commitment to a healthy society includes participation in a variety of different programs, as listed here.- diabetes collaborative - a national program to provide personalized case management services to diabetes patients.- child health insurance program (chip) outreach program - informs low income families on the benefits of enrolling children in the state chip program.- patient centered medical home (pcmh) - Su Clinica Familiar has four level 3 pcmh sites consisting of our harlingen, Texas, brownsville, Texas, raymondville, Texas, and santa rosa, Texas location.- delivery system reform incentive payment (dsrip) 1115 waiver - the clinic expects that the use of electronic medical records, health information exchange, patient centered medical home and coordination with the hospital will lead to a percentage reduction in the number of adult patients with type 1 or 2 diabetes whose hba1c is above 9.0%, otherwise known as poor control.- hrsa outreach and enrollment program - expand current outreach and enrollment assistance activities and facilitate enrollment of eligible health center patients and service area residents into affordable health insurance coverage through the health insurance marketplaces, medicaid, or the children's health insurance program.- access increase in mental health and substance use - to provide primary care mental health and substance use services with a focus on opioid abuse to increase number of staff who are providing mental health and substance abuse services to existing patients. The clinic will also leverage health information technology (it) and provide training to support the expansion of mh and sa services focusing on the treatment, prevention, and awareness of opioid abuse, and their integration into primary care.-diabetes prevention program - through the cdc-led national diabetes prevention program (national dpp), public and private organizations will work together to expand the infrastructure for the nationwide delivery of an evidence-based lifestyle change program to prevent or delay onset of type 2 diabetes among adults with pre-diabetes. The national goal is to expand the national dpp delivery structure, close the enrollment gap so that more participants with prediabetes successfully complete the cdc lifestyle change program, achieve 5-7 % weight loss, and significantly reduce their risk for developing type 2 diabetes. - integrated healthcare improvement - serve a panel of 200 underserved patients, each with 2 or more co-morbidities including diabetes, hypertension, obesity, and depression, with a focus on improving health outcomes. Provide data showing the results for these patients related to the 4 co-morbidities.- project doc (diabetes and obesity collaboration) - the goal is to create an ecosystem in which the private sector, healthcare, and patients leverage technology and collaborate to change the healthcare model.- si Texas - work with the university of Texas health science center at houston - brownsville regional campus to further the aims of the si Texas project.goal 1: at least 45% of salud y vida participants who were identified by the chronic care management team as needing mtm services or bh services will receive said services by the end of year 2.goal 2: at least 20% of mtm program participants will achieve an hba1c of below 9% during the 9 months following the provision of services by the end of year 2.goal 3: at least 20% of behavioral health service program participants will achieve an hba1c of below 9% during the 9 months following the provision of services by the end of year 2. - dsrip 1115 waiver - reduce the overall a1c among the target population to 32.90% or below, continue to improve the proportion of patients with uncontrolled diabetes and will demonstrate an improvement of this proportion from the baseline as defined by hhsc.- Su Clinica is participating in hrsa's advancing precision medicine (apm) project. This participation of the health center 'all of us research' program (aou) will help the center contribute to the achievement of the aou's central goal: to enroll 1 million individuals reflecting the nation's rich diversity and produce meaningful health outcomes for communities across the country, including those historically underrepresented in biomedical research. The apm will also assist in the advancment of the health centers' interoperability functionality, preparedness to use and share patient data, and capacity to participate in future research opportunities. - Su Clinica has launched a telemedicine program in which the center makes available health care services via telemedicine and telehealth to medical and behavioral health clinic patients. - Su Clinica has actively been participating in the following with regards to covid: - covid-19 vaccination capacity support to plan, prepare for, promote, distribute, administer, and track covid-19 vaccines, and to carry out other vaccine-related activities, including outreach and education.- covid-19 response and treatment capacity support to detect, diagnose, trace, monitor, and treat covid19 infections and related activities necessary to mitigate the spread of covid19, including outreach and education.- maintaining and increasing capacity support to establish, modify, enhance, expand, and sustain the accessibility and availability of comprehensive primary care services to meet the ongoing and evolving needs of the service area and vulnerable patient populations.- recovery and stabilization support for ongoing recovery and stabilization, including enhancing and expanding the health care workforce and services to meet pent up demand due to delays in patients seeking preventive and routine care; address the behavioral health, chronic conditions, and other needs of those who have been out of care; and support the well-being of personnel who have been on the front lines of the pandemic. Hpv program - the overarching goal of your proposed program, to increase cervical cancer screening, early detection and navigation to treatment, is highly aligned with the goals and mission of Su Clinica. Many of our patients face significant barriers to regular cervical cancer screening. To that end, Su Clinica is on the cutting-edge of the national transition to primary hpv testing, which offers the opportunity to reach a population of at-risk persons for whom pap testing and pap/co-testing has not been an accessible and/or acceptable option for screening. The impending fda approval of in-clinic self-collection for primary hpv testing, under the supervision of our healthcare providers, will address many barriers to screening faced by our patients. Critical to preventing cervical cancer is ensuring that persons who have a positive screening test receive the necessary clinical follow-up. Our clinic offers complete obstetric/gynecological services, ensuring that proper follow up care will be provided for those who receive a positive hr-hpv test result. Additionally, we are able to leverage our current cprit and hrsa collaborations with md anderson to ensure further ensure that patients receive the care they need. Chronic care management - Su Clinica provides chronic care management (ccm). The scope of work includes: developing comprehensive care plans, regularly monitoring patient health status, coordinating care between different providers, managing medication adherence, providing patient education on self-management of chronic conditions, facilitating care transitions (like hospital discharges), and maintaining open communication with patients through phone or electronic access, all aimed at improving quality of life for individuals with multiple chronic conditions. Remote patient monitoring (rpm) - Su Clinica provides rpm. The scope of work includes: setting up and managing a system to collect patient health data using wearable devices or other remote monitoring technology, regularly reviewing that data to identify trends a