Transcript No Slide Title

California Chronic Care Learning
Communities Initiative Collaborative
Final Outcomes Congress
December 2005
Richmond Health Center
Diabetes 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…”
Community
Health System
Resources and Policies
Self-Management
Support
Revised
Curricula
Improved
referrals
Self-care
Action Plans
Organization of Health Care
Delivery
System
Design
Diabetes Rx.
Standing
Orders
Care
coordination
Decision
Support
Diabetes
Guideline
Paper
Flowsheet
Clinical
Information
Systems
Diabetes
Registry
.
Community
Resources and Policies
•Kaiser
•Laotian community
Informed,
Activated
Patient
Health System
Organization of Health Care
Case management
coordination with
our Health Plan
Productive
Interactions
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes
Informed,
Activated
Patient
Our educational
approach
changed to
support patient
self-management
skills...
Productive
Interactions
Prepared
Practice
Team
The Registry allows
us to proactively
reach out to patients
and make sure they
get all the care they
need…..
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 receive
quarterly lists of their diabetic patients who
require interventions.
Clinical Outcomes
LDL Control <100
Average HbA1c
70
65
60
55
50
45
40
35
% of Patients w/ LDL<100
8.2
8.1
8
7.9
7.8
7.7
7.6
7.5
7.4
7.3
7.2
7.1
7
6.9
6.8
6.7
6.6
6.5
30
25
Oc
t0
No 4
v
0
De 4
c
0
Ja 4
n
0
Fe 5
b
0
Ma 5
r0
Ap 5
r0
Ma 5
y
0
Ju 5
n
05
Ju
l0
Au 5
g
0
Se 5
p
0
Oc 5
t0
No 1
v01
Average HbA1c
75
20
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
Process Outcomes
Pneumococcal Vaccine
Self-Management Goals
100
90
90
80
80
60
50
40
30
20
70
% Patients with Vaccine
70
% of Patients w/ SM Goal
100
60
50
40
30
10
20
0
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct- N
04 04 04 05 05 05 05 05 05 05 05 05 01 ov01
10
0
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
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
Improvements
Patients involved with the Care Model
2%
Providers Using The Care Model
2%
18%
18%
CCLC
West CCC
Others
80%
80%