Our Focus Areas

 

The Center for Health System Improvement (CHSI) serves as the research core of the Tennessee Population Health Consortium and supports research to determine the effectiveness of innovative health system interventions to improve human health. We focus on pragmatic clinical research to evaluate innovative uses of health information technology, lay community health workers, and community-based health resources to improve the delivery of essential health services to underserved populations. We also promote sustainable community-driven health system change. Our work includes the Patient-Centered Outcomes Research Institute-funded  Management of Diabetes in Everyday Life (MODEL) study, which recently demonstrated that health coaching and text messages are effective tools in increasing healthy eating and exercise in patients with uncontrolled diabetes. Learn more about our research.

 

 

The Tennessee Heart Health Network (TN-HHN) works to implement patient-centered interventions in primary care to improve cardiovascular health. As the signature project of the Consortium, TN-HHN was launched January 1, 2021, in recognition that Tennessee's need is great. Our state ranks #3 in cardiovascular disease events because of high rates of obesity, uncontrolled hypertension and diabetes, and tobacco use. The TN-HHN works to help primary care practices implement evidence-based patient-centered interventions to improve quality and outcomes of cardiovascular care across Tennessee. Through TN-HHN, we help participating clinics offer health coaching, in-clinic pharmacists, and motivational text messages – all proven to help patients adopt healthy habits and improve their health. This work is funded by the Agency for Healthcare Research and Quality.

 

 

The Neighborhood Health Hub program uses the Neighborhood Health Hub Model, a new place-based model to extend primary care into neighborhoods of greatest need. The hubs are located in those neighborhoods, and through health coaches provide support for weight loss, blood pressure control, healthy eating strategies, physical activity, medication adherence, and improvement in quality of life. We also address social determinants of health and facilitate access to essential primary and mental health care. An additional goal is to provide satisfaction and trust in health care, as well as addressing the behavioral causes of obesity, hypertension, and diabetes that result in poor health outcomes. We currently have Health Hubs in the Soulsville, Uptown, and South Memphis neighborhoods of our city.

 

 

 

 

 

Tennessee Population Health Data Network (TN-POPnet), our population health disease registry, holds the unique patient health information of more than two million patients. TN-POPnet’s primary purposes are meaningful use of electronic health records, and using the data from electronic health records to improve care for patients with chronic diseases or at risk of chronic disease. Therefore, we work with both providers participating in TN-POPnet and with researchers evaluating the impact of interventions and health outcomes, health services research projects, and pragmatic, real-world clinical trials. TN-POPnet is supported by the UTHSC Tennessee Population Health Consortium, and the Enterprise Data Warehouse (EDW) maintained by the Center for Biomedical Informatics (CBMI).