California Chronic Care Learning Communities Initiative (CCLC) California Chronic Care Learning Communities Initiative (CCLC) Funded by the California HealthCare Foundation

Building a Shared Vision for Chronic Care Improvement For diabetic patients served by nine public hospital clinics, our goal is to: Improve care processes Decrease complications Reduce cardiovascular risk

What do we want to achieve? In 9 months, the CCLC aims to achieve breakthrough improvement in: Control of clinical risk factors Use data and information systems to support pro-active care Improve use of self-management support strategies by patients and providers

Where are we starting from? The U.S. health care system does a poor job of caring for patients with chronic conditions

Disturbing facts 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.

Californians with chronic illnesses vs. Californians receiving good care Californians with chronic illnesses vs. Californians receiving good care (in millions)

Most chronic care is primary care Most chronic care is primary care Percentage of Office Visits According to Physician Specialty, By Primary Dx Source: L Green, Analysis of 1996 Natl Amb Med Care Survey

Where are we starting from at the nine CCLC public clinics? 13,167 diabetic pts. Some clinics report > 20% HbA1c >9 24% of pts. have high cholesterol 43% of pts. w/hypertension 24% of pts. obese 10% of pts. smoke

Where are we starting from at the nine CCLC public clinics? Fragmented care Inadequate information systems Lack of pt. self- mgmt. Irregular testing/exams Ccare mgmt. left to busy PCPs Low ability to stratify pts. by risk

We know what is possible

Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Improved Outcomes Chronic Care Model

Ocean Park Health Center, SF Community Health Network Participated in California Quality Improvement Collaborative and, in 6 months, achievements include: ↑in % pts. w/LDL <100 from 38% to 53% ↑in % pts. w/controlled BP from 36% to 53% ↑ in foot exams from 12% to 65% ↑in self-mgmt. goal setting from 0% to 40%

Bureau of Primary Health Care Health Disparities Collaboratives 23 community health centers achieved ↓HbA1c levels by 1%

Other public hospital clinics have achieved impressive outcomes Santa Clara Valley Medical Center’s Chronic Care Management Program, in 2 years: ↓HbA1c levels by 1% Edward R. Roybal Comprehensive Health Center, of the LA County DHS, in 6 months: ↓avg. LDL from 115 to 101 Avg. LDL held at 105 after 1 yr.

Other public hospital clinics have achieved impressive outcomes San Mateo Medical Center Diabetes Outpatient Education Program ↓% pts. w/HbA1c >8 from 52-54% to %

Challenges Financial instability of public hospitals and health systems

“The health care safety net is unraveling fast precisely when more families are falling into it.” San Francisco Chronicle December 29, 2002

Other challenges to improving chronic care in public hospitals/health systems No reimbursement for non-physician care Inadequate information systems Chaotic, overstressed primary care clinics Multiple patient languages and few interpreters Low health literacy Difficulty changing job descriptions of clinic staff Delivery system geared toward acute illness

Strengths: Why changing chronic care in public hospital systems will make a difference Health disparities: patient population is 78% people of color, predominantly low-income Training next generation of health care professionals Comprehensive systems of care: potential to improve along continuum of care

Facilitators for improving chronic care in public hospitals/health systems Leadership/champions Culture of “doing the right thing” Why do some organizations perform better than others? Virtually every study examining this question gives two reasons: –Leadership –Culture Good leadership and a quality-oriented culture enable organizations to overcome the barriers

“An impressive group of individuals throughout California have made major strides -- though limited in the proportion of the safety net population reached -- in improving chronic care. These individuals are the founders of a larger movement for chronic care improvement in California’s safety net.” Examining Chronic Care in California’s Safety Net

CCLC (9-12 months time frame) Select Topic (develop mission) Planning Group Develop Framework & Changes Participants (9 teams) Prework LS 1 P S AD P S AD LS 3 LS 2 Supports Visits PhoneAssessments Monthly Team Reports Congress, Guides, Publications etc. AD P S Expert Meeting

Learning Session I Agenda Today: Get ideas! Tomorrow: Plan changes!