California Chronic Care Learning Communities Initiative Collaborative

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California Chronic Care Learning Communities
Initiative Collaborative Final Outcomes
CongressDecember 9, 2005

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San Mateo Medical Center

• Location Primary Care Clinic in the Main Campus
  of San Mateo Medical Center
• Size 122 Patients From Dr Rebecca Ashes panel
• with diagnosis of Diabetes, Hypertension,
  and
• Hyperlipidemia
• Population Served All residents of San Mateo
• County for health care needs with an
  emphasis on
• education and prevention, without regard for
  
• ability to pay.

ICIC Website http//www.improvingchroniccare.org/

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San Mateo Medical Center
Health System
Community
Resources and Policies
Organization of Health Care
DeliverySystem Design
Decision Support
ClinicalInformationSystems
Self-Management Support

• Use of Diabetes
• care flow sheet
• Utilizing CDEMS to reach out to patients with
  poor control

• Group visits
• with Dr Ashes
• patients
• CDEMS for
• better tracking
• Developed
• Foot stamp
• Expanded role
• for MAs
• (Foot exam prep
• and Action Plans)

• Diabetes Basic
• classes
• Increased
• communication
• with clinics
• endocrinology
• ophthalmology
• and podiatry

• Patients are
• encouraged to
• attend self-help group
• Patients are reminded to bring all
• medications to each visit
• Each patient is given
• a Diabetes Care card
• to track current labs
• and meds

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San Mateo Medical Center
Health System
Community

• Presentations to hospital committees for
• spread of registry
• Collaboration with Kaiser on PHASE project

Organization of Health Care
Resources and Policies

• Referrals to Active for Life Program
• Smoking cessation program
• Education Materials from California
• Diabetes Society and
• Nutrition Education classes
  sponsored by
• American
  Diabetes Association

Informed, Activated Patient
Prepared, Proactive Practice Team
Productive Interactions
Functional and Clinical Outcomes
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San Mateo Medical Center
Informed, Activated Patient
Prepared Practice Team
Productive Interactions

• Improved patient tracking with use of CDEMS
  registry
• Planned Diabetes Group Visits
• Diabetes Basic Facts classes
• Improved teamwork of clinic staff and expanded
  roles for MAs
• Establishment of Action Plans for better
  self-management
• Development of foot stamp and process for
  providers to perform
• foot exams

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Delivery System Design

• Team Roles Tasks
• MA prepares patient for a foot exam
• MA initiates Action Plan with patient, MD and RN
  follow up with them
• Planned Visits
• Group visits with Dr Ashes patients
• Continuity
• CDE, RN and MA conducting Diabetes Basic Facts
  classes monthly in English and Spanish
• - Increased communication with specialty
  clinics
• Follow-up
• CDEMS registry to track visits and labs

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Functional and Clinical Outcomes

• Baseline Actual Target
• Dec 04 Oct 05
• HbA1c lt 7.0 36.9 44.6 60
• Self mgt goals set 32.3 85.3 70
  
• LDL lt 100 45.9 59.8 70
• Foot exam 28.5 77.1 60
• BP lt 130/80 23.4 35.0 40
• On Ace/ARB 76.6 83.3 75

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Barriers

• Resistance to change improving teamwork by
  adjusting roles of clinic staff
• Labs not interfaced with CDEMS currently
  working with administration and IT for solution
• Time we continue to meet weekly as a team at
  lunch and enter data manually

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Keys to Sustaining and Spreading Our Chronic Care
Improvements

• Success achieved through continued support from
  senior leadership
• To spread and sustain change we recently obtained
  grant funds to interface labs with CDEMS and for
  ongoing clinical data entry and IT support

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Group Visit Session at San Mateo Medical Center
This visit was very helpful. I have learned
what to eat and how to exercise.
I could start checking my sugar at home.
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Patients Comments after a Group Visit Session

• I have learned the Basic Facts of Diabetes
  and I will exercise more and have better eating
  habits.

• I know what happens when you dont take your
  medicine. I will follow all lessons learned.

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THANK YOU