California Chronic Care Learning Communities Initiative Collaborative Final Outcomes Congress December 2005 Richmond Health Center Diabetes project.

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Presentation transcript:

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…”

Delivery System Design Decision Support Clinical Information Systems Self-Management Support Health System Resources and Policies Community Organization of Health Care Diabetes Registry Diabetes Rx. Standing Orders Care coordination Diabetes Guideline Paper Flowsheet Revised Curricula Improved referrals Self-care Action Plans

Informed, Activated Patient Productive Interactions Prepared, Proactive Practice 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, Activated Patient 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….. 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 receive quarterly lists of their diabetic patients who require interventions.

Clinical Outcomes

Process Outcomes

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