california chronic care learning communities initiative collaborative final outcomes congress...
TRANSCRIPT
California Chronic Care Learning Communities Initiative
Collaborative
Final Outcomes Congress December 2005
Richmond Health CenterDiabetes project
Collaborative Team Members
Contra Costa Health Services
Richmond Health Center
Mr. Willie C talks about the care he received as a diabetic:
“I think the best thing was becoming a diabetic; no seriously, it changed my whole lifestyle…”
DeliverySystemDesign
Decision Support
ClinicalInformation
Systems
Self-Management Support
Health System
Resources and Policies
Community
Organization of Health Care
Diabetes Registry
Diabetes Rx.
Standing Orders
Care
coordination
Diabetes
Guideline
PaperFlowsheet
Revised Curricula
Improved referrals
Self-care Action Plans
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Functional and Clinical Outcomes
Health System
Resources and Policies
Community Organization of Health Care
•Kaiser•Laotian community
.
Case management coordination with our Health Plan
Informed,ActivatedPatient
ProductiveInteractions
PreparedPractice Team
The Registry allows us to proactively reach out to patients and make sure they get all the care they need…..
Our educational approach changed to support patient self-management skills...
Clinical Information Systems• Registry Data:
Home built registry includes >8000 names. Full Data for 1500 patients in W. Contra
Costa.
• Individual Patient Care: Registry decision support guides interventions Non-clinician staff can use standing orders based on the registry
• Population Interventions: Provider Feedback has spread-100 PCPs
receivequarterly lists of their diabetic patients who require interventions.
Clinical OutcomesAverage HbA1c
6.56.66.76.86.9
77.17.27.37.47.57.67.77.87.9
88.18.2
Aver
age
HbA
1c
LDL Control <100
20
25
30
35
40
45
50
55
60
65
70
75
Oct 04 Nov 04 Dec 04 Jan 05 Feb 05 Mar 05 Apr 05 May 05 Jun 05 Jul 05 Aug 05 Sep 05 Oct-01 Nov-01
% o
f Pat
ients
w/ L
DL<1
00
Process Outcomes
Self-Management Goals
0
10
20
30
40
50
60
70
80
90
100
Oct04
Nov04
Dec04
Jan05
Feb05
Mar05
Apr05
May05
Jun05
Jul05
Aug05
Sep05
Oct-01
Nov-01
% o
f Pat
ient
s w
/ SM
Goa
l
Pneumococcal Vaccine
0
10
20
30
40
50
60
70
80
90
100
Oct 04 Nov 04 Dec 04 Jan 05 Feb 05 Mar 05 Apr 05 May 05 Jun 05 Jul 05 Aug 05 Sep 05 Oct-01 Nov-01
% P
atie
nts
with
Vac
cine
Barriers
• Time for the team to meet is never enough.
• Time for team members to develop and test new materials has been a challenge.
• We’ve seen some wonderful results from our registry, but it is still under development and not easy to integrate into clinic flow.
The Patient Voice Part 2:
A planned diabetic visit
It’s the time we spend, just like now, how we spend time talking ….. It’s been a very positive thing for me…
Keys to Sustaining and Spreading Our Chronic
Care ImprovementsPatients involved with the Care Model
2%18%
80%
Providers Using The Care Model
2%18%
80%
CCLC
West CCC
Others