Works in collaboration with the Director, Health Promotion and Disease Prevention to support clinical delivery partners with referral activity for the National Diabetes Prevention Program (NDPP) and alignment with the American Medical Association’s (AMA) prediabetes care quality measures. Leads the development of a quality dashboard and prepares reports reflecting NDPP delivery and outcomes, interventions addressing patient social needs, and progress toward funding deliverables. Develops and manages provider engagement, develops and monitors measurable outcomes as defined by program goals. In collaboration with the CHWB Social Care Team, improves clinical practice team’s awareness of services to support diabetes prevention in the patient population and improve referrals to the evidenced based intervention Knows, understands, incorporates and demonstrates the mission, vision and values of Trinity Health in behaviors, practices and decisions. Develops and maintains strong and supportive working relationships with clinical delivery partners including Trinity Health regional health ministries and contracted partners, the Clinically Integrated Networks, federally qualified health centers, Medical Group and with Trinity Health Ambulatory Quality leadership. Builds and sustains strategic initiatives with these groups to drive provider awareness, adoption and implementation of program operations. Develops and delivers training and technical assistance, including development of program implementation toolkits, for all clinical delivery partners for national strategic population health quality improvement project focused on N/MDPP-related activity, participant recruitment and referral, and AMA prediabetes care quality metrics. Leads the efforts to operationalize the AMA prediabetes quality measures with all Trinity Health stakeholders Monitors quality dashboard metrics to assess progress on NDPP outcomes, prediabetes care, and related interventions for addressing patient social needs. Conducts structured landscape assessments of current workflows, referral processes, and provider knowledge to identify operational gaps and barriers to referrals and designs and conducts key informant interviews with clinical and operational stakeholders; synthesize findings to inform workplan activities, resource allocation and implementation strategies. Identifies, onboards, and supports provider champions to advance program goals. Plans, develops and facilitates physician champion training workshops and staff education. Contributes thought leadership and performs other tasks as needed to engage with evaluators and researchers on studies and scholarly publications. Manages the relationship between AMA and Trinity Health in alignment with the Memorandum of Understanding (MOU). Engages in other duties as assigned in relationship to clinical and social care integration at Trinity Health. Maintains a working knowledge of applicable Federal, State and local laws/regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
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Job Type
Part-time
Career Level
Mid Level
Number of Employees
251-500 employees