Small Health Care Provider Quality Improvement - Aria Community Health Center (Aria CHC) proposes “Juntos: Together for Purpose-Driven Care”, a four-year quality improvement initiative that will strengthen the delivery of whole-person, team-based care for rural and medically underserved populations across California’s San Joaquin Valley. Serving more than 37,000 patients in Fresno, Kings, and Tulare Counties, Aria CHC cares for communities that experience significant barriers to health, including poverty, chronic disease, limited access to care, workforce shortages, language barriers, and challenges navigating an increasingly complex healthcare system. The project is guided by the Institute for Healthcare Improvement (IHI) Model for Improvement and the Map-Enabled Experiential Review (MEER) approach. The project will strengthen collaboration among multidisciplinary care teams and embed quality improvement into daily practice. By creating shared accountability for outcomes and expanding the use of data-informed decision making, Aria CHC will build a more coordinated, proactive, and patient-centered model of care. The project is organized around three interconnected strategies. First, Aria CHC will build a culture of quality improvement by establishing multidisciplinary teams that regularly review performance, identify barriers to care, test solutions, and share accountability for results. Second, the organization will strengthen data collection and utilization by expanding its capacity for population health management, care-gap identification, performance monitoring, proactive outreach, and data-informed decision making. Third, Aria CHC will enhance financial sustainability through improved documentation, coding, revenue optimization, and alignment with value-based care programs, ensuring that quality improvement efforts can be maintained long after the grant period ends. "Juntos" will also support investments in workforce development by expanding staff skills in quality improvement, population health management, care coordination, data analytics, and performance improvement. Through ongoing training, coaching, and multidisciplinary learning, staff will gain the knowledge and tools needed to deliver more coordinated, proactive, and patient-centered care. These investments will strengthen organizational capacity, improve workforce engagement and retention, and create sustainable systems that support continuous improvement. The project is expected to produce measurable improvements in chronic disease management, preventive care, care coordination, and patient engagement. Aria CHC will focus on improving performance on priority quality measures related to hypertension control, diabetes management, cardiovascular disease prevention, tobacco cessation, depression screening and follow-up, and preventive cancer screening while reducing care gaps and improving continuity of care. Patients will benefit from better coordinated services, earlier intervention, improved access to support, and a healthcare experience centered on their needs and goals. Through "Juntos", Aria CHC will strengthen the systems, workforce, and partnerships needed to deliver more coordinated, proactive, and patient-centered care. The project will create lasting improvements in quality, health outcomes, and health equity for rural and medically underserved communities across California's Central Valley.
