Chronic Disease Management at a Community Free Clinic Bill Cayley MD MDiv

Objectives Diabetes program development Target disease identification CDM processes and programs Educational experiences Community free clinics are an important part of the safety net for uninsured persons, and often serve as the medical home for uninsured patients requiring care for chronic illness. This presentation will describe the process of expanding a grant-funded diabetes care program at a community free clinic into a broader chronic disease management program for uninsured patients. Specifically, this presentation will address: 1) the process of developing and funding the initial diabetes management program, 2) the identification of target chronic diseases to be addressed by a CDM program, 3) the development of clinical processes and programs to support CDM for uninsured patients, and 4) the incorporation of educational experiences for medical students and residents into the free clinic chronic disease management program.

Background Chronic disease management (CDM) Uninsured Patient self-management Clinical support Health promotion Prevention of further disease Multidisciplinary care Uninsured 15% of US population Free clinics serve as “medical homes” Effective chronic disease management (CDM) requires patient self-management, clinical support, health promotion, prevention of further disease, and multidisciplinary care coordination. (1) However, approximately 15% of the US population remains uninsured, and thus at risk for suboptimal chronic illness care. (2) Free clinics often serve as the medical home for uninsured patients. It is essential that free clinics have the capacity to effectively manage patients’ chronic disease needs, yet few models of CDM for the uninsured exist. Dorr DA, Wilcox A, Burns L, Brunker CP, Narus SP, Clayton PD. Implementing a multidisease chronic care model in primary care using people and technology. Dis Manag. 2006 Feb;9(1):1-15. PMID: 16466338 2) Health, United States, 2007. National Center for Health Statistics, Centers for Disease Control and Prevention. (http://www.cdc.gov/nchs/data/hus/hus07.pdf)

Project Partners For this project, the Chippewa Valley Free Clinic partnered with the University of Wisconsin Department of Family Medicine (Eau Claire Family Medicine Residency) and the University of Wisconsin (UWEC) School of Nursing.

Diabetes program WI Partnership Program: $50,000 grant Program components Twice monthly diabetic clinics Staffing with volunteer nurses and clinicians Protocols for nurse-managed care Quality indicators Paid program coordinator Community-academic partnership In 2006 the Chippewa Valley Free Clinic developed a grant-funded diabetes program to provide chronic care for diabetic patients. The program was funded with a $50,000 grant from the Wisconsin Partnership Program. Features of the program included: twice monthly diabetic clinics, staffing with volunteer nurses and clinicians, protocols for nurse-managed care, quality indicators, paid staff position for program coordinator. The program began operation in February 2007. The program was designed to be a community-academic partnership for development and dissemination of a model for chronic diabetes care for the uninsured.

Patient characteristics Patients in program 26 Average age 45.6 Average weight 218 # Average BP 142/83 Average A1C 8.6 Average LDL 100.1 Source: UW-SMPH WPP Planning Grant Final Report – Chippewa Valley Community Diabetes Project

Target chronic diseases “Healthy WI 2010” Reducing health disparities Access Obesity & lack of activity Social and economic factors Tobacco abuse Target conditions Hypertension CAD Heart failure COPD Asthma Depression Expansion of the CV Free Clinic diabetes program into a chronic disease management program was planned to address the following components of the state health plan as outlined in Healthiest Wisconsin 2010: Eliminating (Reducing) health disparities. By designing comprehensive chronic disease management for a regional free clinic, the program would assist in reducing health disparities between persons with and without health insurance in the regional Eau Claire area. Access to primary and preventive health services. The target population would receive both primary and preventive services in the treatment of chronic disease through screening and interventions. Overweight, obesity, and lack of physical activity. As these are often risk factors or co-morbidities for chronic disease, overweight, obesity and lack of physical activity would be addressed within the treatment protocols. Collaborations would be sought with others who are addressing these problems in the Eau Claire area (eg., Healthy Communities 2010). Social and economic factors that influence health. Social and economic factors influencing health would be studied for CVFC patients with chronic disease conditions. Findings would be incorporated as design elements in the resulting health management program. Tobacco abuse. As smoking is a major cardiovascular risk factor, approaches would be sought for motivating and intervening with our population to reduce tobacco use. Target conditions for chronic disease management were identified from among Wisconsin’s 54 health priority conditions: hypertension, coronary artery disease, heart failure, chronic obstructive pulmonary disease (COPD), asthma, and depression. (1) 1) Healthiest Wisconsin 2010: A Partnership Plan to Improve the Health of the Public. (http://dhfs.wisconsin.gov/statehealthplan/shp-pdf/pph0276phip.pdf)

CDM program goals Define and describe the population of CVFC patients with chronic illness Broaden the existing diabetes program into a chronic disease management program for uninsured patients Improve chronic disease care for uninsured patients in Western Wisconsin The goals, outcomes and objectives for developing a CDM program were:   GOAL 1: Define and describe the population of CVFC patients with chronic illness. OUTCOMES AND OBJECTIVES: a) Identify the population of CVFC patients with chronic diseases, including diabetes, hypertension, coronary artery disease, heart failure, COPD, asthma, and depression; b) Develop a registry documenting chronic disease diagnoses, comorbidities, patterns of care and clinic attendance; c) Develop measures for assessing chronic illness care processes, chronic illness care outcomes (e.g., emergency visits, hospitalizations, satisfaction), and the function of CVFC as a “medical home” (accessibility, longitudinality, comprensiveness of care, coordination of care), and patient-oriented outcomes; d) Describe the barriers to optimal chronic illness care that are identified in the process of registry development. GOAL 2: Broaden the existing diabetes program into a chronic disease management program for uninsured patients. OUTCOMES AND OBJECTIVES: a) Review published literature to identify current best-practices for providing chronic illness care to resource-poor or uninsured individuals; b) Identify the key barriers to chronic disease care for CVFC patients that can be addressed through CVFC programs; c) Identify clinic strategies that may be useful in addressing these barriers; d) Identify which components of chronic disease care for our patients are disease specific, and which are common to the experience of chronic disease; e) Develop a clinic strategy for incorporating chronic disease care into clinic operations, both in dedicated “chronic disease” clinics and in the regular general clinics held at CVFC. GOAL 3: Improve chronic disease care for uninsured patients in Western Wisconsin. OUTCOMES AND OBJECTIVES: a) Develop a plan for sharing “Lessons learned” from the CVFC chronic disease management program with other area free clinics.

Educational experiences Family Medicine residents Free clinic experience during Community Medicine Primary Care medical students Observation of DM clinic program Barriers Scheduling Supervision requirements Educational experiences have been incorporated into the Free Clinic in two ways: 1) Family Medicine residents rotate through the Free Clinic as part of a required Community Medicine rotation, and 2) Medical Students observe the Free Clinic diabetes program during their Primary Care Clerkship rotation. To date, scheduling barriers and supervision requirements have prevented continuity involvement of resident physicians in patient care during the diabetes clinics.

Where are we now? WPP Collaboration planning grant Application for 2008 not funded Weaknesses: Need for free-clinic specific model? Areas CVFC falling short in CDM? Relation between DM program and CDM program? CVFC program development CDM group working on protocols SWOT analysis Complete strategic planning The application for WPP funds for a collaboration development grant for 2008 was not funded. Primary weaknesses in the grant application identified by reviewers focused on: The need for a discussion of what aspects of the clinic make it such that other CDM models would not work. The need for further description of how the CVFC is falling short in meeting the needs of chronic illness patients. The need to further articulate how the prior diabetes management project relates to this project. At present, the CDM work group continues to work on developing protocols for care of CVFC patients with chronic disease. The CDM group has also completed a “SWOT” (Strengths, Weaknesses, Opportunities and Threats) evaluation of the diabetes program as it bears on further CDM program development. Further development of the CDM program has been put on hold pending the results of the clinic’s current strategic planning process. Once the strategic planning process is completed the relationship of the CDM efforts and the medical education efforts to the clinic’s strategic plan will be assessed, in order to determine the most appropriate next steps.

Funding for this project was provided by the Wisconsin Partnership Program through the UW School of Medicine and Public Health and the Public Health Oversight and Advisory Committee. Approval was obtained from the UW Madison Health Sciences IRB for protocol development activities.

THANKS!