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Overview and Results: What We Have Accomplished

California Chronic Care Learning Communities Initiative Collaborative. Overview and Results: What We Have Accomplished. Final Outcomes Congress - December 9, 2005 Wendy Jameson, Director Angela Hovis, Improvement Advisor. Prevalence of Chronic Disease in California.

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Overview and Results: What We Have Accomplished

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  1. California Chronic Care Learning Communities Initiative Collaborative Overview and Results:What We Have Accomplished Final Outcomes Congress - December 9, 2005 Wendy Jameson, Director Angela Hovis, Improvement Advisor

  2. Prevalence of Chronic Disease in California • 12 million in CA with chronic disease • Hypertension • Asthma • Congestive Heart Failure • Diabetes • 4 million of chronically ill Californians seek care in the safety net 2 million have diabetes Bodenheimer, T., Examining Chronic Care in California’s Safety Net,Oakland: California Health Care Foundation, July 2003.

  3. What Do Patients with Chronic Illness Need? • Care geared towards: • Preventing bad outcomes (amputation, blindness, cardiovascular disease) • Motivating and helping patients make lifestyle changes • A tracking system, or patient registry, to make sure no one slips through the cracks

  4. Chronic Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

  5. In General, American Medicine Does a Poor Job Caring for the Chronically Ill • Half of patients hospitalized with congestive heart failure are readmitted within 90 days. • 63% with diabetes have HbA1c levels > 7.0%. • 66% hypertensives have BP out of control. Ni et al. Arch Intern Med 1998;158;231. Saydah et al. JAMA 2004;291:335. JNC 7. JAMA 2003;289:2560.

  6. California Chronic Care Learning Communities CollaborativeBrought to You By... • California Health Care Safety Net Institute • California HealthCare Foundation • Kaiser Permanente • Core faculty representing: • Improving Chronic Illness Care, Group Health Cooperative • Institute for Healthcare Improvement (training) • Chronic care champions from 3 CAPH member public hospital systems

  7. California Chronic Care Learning Communities CollaborativeParticipants • Alameda County Medical Center • Arrowhead Regional Medical Center • Contra Costa Health Services • San Francisco Department of Public Health • San Francisco General Hospital • San Mateo Medical Center • Santa Clara Valley Medical Center

  8. Breakthrough Series Collaborative Model Participants (teams/pilot sites) Review Measures & Change Package Pre-work: (Aims and Measures) P P P Congress, Next Steps A D A D A D Select Topic (develop mission) S S S LS 3 LS 1 LS 2 Planning Group & Faculty Supports Email Visits Phone Assessments Monthly Team Reports

  9. California Chronic Care Learning Communities CollaborativeGoals For diabetic patients served by nine public hospital clinics, our goal was to: • Improve care processes • Decrease complications • Reduce cardiovascular risk

  10. Three Key Focus Areas • Use of data and information systems to support pro-active care • Control of clinical risk factors • Each team set goals, based on Bureau of Primary Health Care Health Disparities Collaboratives • Better use of self-management support strategies by patients and providers

  11. Where did we start? • 9 clinics serving over 13,000 diabetics; many poorly controlled • All at risk for cardiovascular disease • Each clinic chose a small pilot population of 100-200 patients of 1-3 physicians

  12. National data - Source: NHANES III (1994) and Behavioral Risk Factor Surveillance System data (1995); Saaddine, J.B. et. al, Annals of Internal Medicine 2002; 136:565-574. HEDIS data - Source: The State of Health Care Quality: 2005, National Committee for Quality Assurance, Washington, DC, 2005. Chobanian AV et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JAMA 2003;289:2560-2572

  13. How Did We Do?Mean Assessment Scores and Comparisons

  14. Roll-Up Graphs

  15. Roll-Up Graphs (cont.)

  16. Roll-Up Graphs (cont.)

  17. Roll-Up Graphs (cont.)

  18. Roll-Up Graphs (cont.)

  19. Highlights Statins – 4 Teams 3 showed improvement 1 already at or above goal and sustained ACE-ARB – 6 Teams 4 showed improvement 1 already at or above goal and sustained

  20. Highlights Retinal Eye Exam – 4 Teams 3 showed improvement

  21. Highlights Foot Exam – 5 Teams 4 showed improvement Pneumococcal Vaccine – 4 Teams 2 showed improvement

  22. Highlights Self-Management Goals – 8 Teams All 8 showed improvement!

  23. Highlights A1c Tests – 9 Teams 5 showed improvement 1 already at goal and sustained LDL Test – 9 Teams 5 showed improvement

  24. Highlights BP Control – 9 Teams 4 showed improvement 1 already at goal and sustained

  25. Highlights LDL Control – 9 Teams 4 showed improvement

  26. Highlights A1c Control – 9 Teams Average < 7: 2 showed improvement % < 7: 3 showed improvement

  27. Challenges to Improving Chronic Care in Public Hospitals & Health Systems • No reimbursement for non-physician care • Information systems not geared for tracking chronic care patients • Chaotic, overstressed primary care clinics • Patients with limited English & low health literacy • Difficulty changing job descriptions of clinic staff • Bureacracy • Delivery system geared toward acute illness

  28. Public hospital Systems Can Have the Most Impact on Disparities in Chronic Care • Health disparities: patient population is 78% people of color, predominantly low-income • Comprehensive systems of care: potential to improve along continuum of care • Training next generation of health care professionals

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