West Central Cluster Coal Country Community Health Center

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West Central ClusterCoal Country Community
Health Center
(A Diamond in the Rough )
Locations Beulah, Center, and Halliday
Population Served -Approximately 300
Diabetics -Ethnic mix of Native Americans and
Caucasians
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AIM Statement
Using the Care Model, we will aim to delay or
decrease the complications of diabetes for our
diabetic patients Selected Measures

1. Average HbA1c lt7 2. 90 have two HbA1cs in
last year 3. 70 have Self-management goals 4.
75 patients gt55 on an ACE or ARB 5. 40 BP
lt130/80 6. 70 LDLlt100 7. 12 smokers 8. 70
annual dilated eye exam 9. 90 annual foot
exam 10. 50 annual Microalbuminuria 11. 90
annual influenza vaccine 12. 90 Pneumococcal
vaccine
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Self-Management

• Currently Testing
• Have Self Management Goals set by providers for
  all diabetic patients.
• Implemented into our Delivery System
• Use of the Self-Management tool by the providers.
• Self management goals set at each education
  visit

Delivery System Design

• Currently Testing
• Analyze if brochure is being distributed and
  patient reaction to brochure.
• Implemented into our Delivery System
• Recreational brochure will be presented to all
  diabetic patients.
• Placing BMI chart in each patient room for easy
  access to doing BMIs
• Standing Orders for diabetes to help expedite
  clinic flow
• Identifier on charts after data entered in PECS
• CGMS will be used as ordered by providers

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Clinical Information System

• Currently Testing
• Provide PECs report to providers.
• Implemented into Delivery System
• All patients entered into PECs for Dr Garman and
  Dr Jackson.
• Currently Testing
• Are the providers using the PECs patient sheets
  that are in charts.
• Education to staff and providers on use of PECS
  sheet.
• Implemented into Delivery System
• PECs sheets were revised and implemented into
  all patient charts.
• Standing orders to aid our staff in obtaining
  tests prior to diabetic patient visit with
  provider.
• Use of the CGMS unit.
• BMI charts in all patient rooms.

Decision Support
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Healthcare Organization

• Currently Testing
• Currently testing use of an EHR ,with aid from
  NDHCRI, to improve workflow in our facility.
• Evaluating the phone calls to nursing
• Auditing PECS data entry
• Implemented into our Delivery System
• Use of Andrea for Data entry when she is
  available
• Implemented and educated Ali for data entry on a
  part time basis
• Trained and incorporated use of PDSA tool into
  the CQI committee.
• Currently Testing
• Developing a recreational brochure
• Implemented into our Delivery System
• Educating CCCHC Board of Directors to
  Collaborative
• Collaborating with Dakota Diabetes Coalition.

Community
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Functional and Clinical Outcomes

• Measures Goal 5/1/05

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Senior Leadership

• The CCCHC CEO and Board of Directors have
  adopted the collaborative style and mission
  within the organization for Quality Improvement.
• The Medical Director is a part of the
  collaborative committee and reports monthly to
  the Board of Directors of testing and
  implementation of change that we are working on.
• Center Level
• Monthly newsletter article.
• Carry over to CQI and EHR committees.
• Update on collaborative at Med staff and nursing
  meetings.
• Staff Education fair booth.
• Community Level
• Board of Director report.
• Local newspaper articles about collaborative and
  diabetes care.
• We will be providing education on diabetes to
  local schools this fall.

Communication Plan
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Anticipating Barriers and Issues

• Those the team can resolve
• Develop policy for PECS users.
• Regular communication to staff.
• Spread ideas to all staff not on team
• Adequate education to staff
• PECS
• Those that leadership needs to address
• EHR Purchase and Implementation
• Braddock scheduling system
• Funding for time and equipment
• C-Freedom
• Communication system (telephone)

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Patient Story

• LS is a 61 year old female who presented to
  our clinic with an Hgb A1C of 7.6. She is 66
  inches tall and weighs 246 lbs. She reports she
  has no formal exercise program and monitors her
  BS when she feels it may be high. LS is unaware
  of monitoring carbohydrates. She is presently
  taking Avandia 8 mg and Glipizide 5 mg. Her BP
  was 166/72. We asked LS to change her Avandia to
  Metformin 1000 BID and visit with our diabetes
  educator. During education she learned the
  importance of monitoring her diet, blood sugars
  and adding exercise to her regime. She admitted
  to having a lot of stress in her present job and
  is looking at retiring from this job. Before
  leaving, a self-management goal of walking 20
  minutes 5 days per week was set by LS. We asked
  her to return in 1 month with a diary of her food
  intake, exercise done and Blood sugars BID. We
  saw LS monthly for education and provider visits.
  Recently we saw LS after 3 months of close
  observation and found her weight to be 242 so has
  had a loss of 4 lbs. She is walking for 20
  minutes twice a day and feels much better. She
  takes her BS BID and her BS is running 90 - 130.
  LS has been keeping a diary of food intake and is
  feeling comfortable
• with choosing foods.

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Staff Story
Being a part of the Collaborative for the last 3
months has certainly been an exciting process for
me. Ive learned so much about Diabetes,
patient-set goals and the care that we, as a
Clinic, can provide the patient. It takes
everyones involvement to see progressive changes
within the patient. In order for it to be a
success, we all have to work together as a team.
My part in the Collaborative is to create a
database for each Diabetic patient and to update
the database each time they are seen by their
Provider. Its exciting to see their reactions
as they reach their target goals and Im excited
for them too! Karla Guttormson Ward Clerk/MIS
Contact Coal Country Community Health
Center Beulah, ND
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National Key Measures
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National Key Measures
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Additional Key Measures
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Additional Key Measures
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Additional Key Measures
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Organization Story
The Medical Health Disparities Collaborative has
impacted Coal Country Community Health Center
(CCCHC) positively in several ways, including

• It has developed a Team Work approach
  throughout the organization on accomplishing
  goals and objectives.
• Has created a climate of high energy and a
  desire to learn throughout the organization.
• A Continuous Quality Improvement Committee and
  an Electronic Health Record Committee have been
  developed to assist in raising-the-bar on the
  level of excellence at CCCHC.
• Patients have taken ownership of their disease
  management.
• Administration and the Board of Directors have a
  clearer understanding of the quality of care
  being provided at CCCHC.
• Dawn Berg, CFO/COO