diabetes collaborative disparity

McKinney Community Health Center

Diabetes Collaborative Disparity

By Roberto Garcia, MD


Introduction

*Objective:

Raise awareness about Diabetes Collaborative issues in the community.


Topics of Discussion

Overview about Health Disparities Collaborative :

-What? When? Why? How?

-How DC affected MCHC.

-Diabetes Collaborative:

The Change.

-Our Challenges

-The Future.


What is the Health Disparity Collaborative (HDC)? A federal initiative created to

improve health care in people with chronic diseases through CHC.

The Diabetes Plan is just one of multiple programs that constitute The Health Disparity Collaborative.

Other programs: CVD, Depression, Asthma and HIV.


When was the HDC created?

The Disparity began with 5 Collaborative teams focusing on DM in Sept.1998.

Today there are > 600 CHC teams. Has spread to 4 others Chronic

Illnesses. MCHC introduced DC in Sept.

2002.


Why?

There are 125 Million people with chronic diseases in USA.

Chronic Diseases(CD) accounts for >70% of all deaths in USA.

CD cuts 1/3 of potential years/life in people >65 years.

Accounts 65% of all medical costs. (510 billion dollars/year)


How does it works?

Is organized around The Care Model:

-Self Management.

-Decision Support.

-Clinical Information System.

-Delivery System Design.

-Organization of Health Care

-Community.


P: Is our proposal or problem.D: Do it. How?S: Study/ Collect results.A: Action/Implementation.

PDSA Cycle: The Testing Machine


How participating in DC affected MCHC? Hypothetic Case Hypothetic Case (real life statistic):

*Mr. McKinney is a diabetic patient who came to MCHC on Sept. 2002.

-HBAIC: 12 ; Cholesterol: 247 mg/dl.

-LDL: 189.

-BP: 149/95.

-Not on ACE INH.or ASA or statin.

-No Micro-albumin/No shots.

-His overall CARDIAC RISK: 95%.


…Case…

Mr. McKinney returns to our center for the next 3 years.

Today:

-His HBAIC is 8.1 (dropping 4 points)

-BP: 136/80.

-Cholesterol: 199 (20%). LDL: 109 (43%). He is taking ACE INH., ASA, statins. Neg. Micro-albumin test.

-His overall fatal risk is reduced to 27%.


Change

In Oct. 2003 our DC team underwent a series of changes:

-Team restructuring, reorganizing, new team members added.

-These changes gave us new direction and leadership.


..change.. Our registry size has increased 334% (new

patients)=375. Total registry=535. HBAIC has declined from 8.5 to 8.1 DC has spread to 2nd. site . New team members(DDC/SCS/PRA/TL). 1 grant project has been approved for $75,000. Updated PECS system. DC has been introduced as Quality Assurance (QA)

Key. Monthly report is disclosed on QA/Provider Meeting. DC team member has been introduced to the Board of

directors. Patient Medication Assistance/Free Glucometer+DM

supply Programs.


-Raise awareness of DC/HD issues in our own organization.-Keep “The Change” running.-Make Standing orders of DC/HD policies in all sites and providers.-Patient Referrals to Foot/Eye Specialist.-Improve DM Education/Self Management Goals.-Maximize Immunizations.-Reduce HBAIC <7.5. By 2007.-Increment of our patient registry to 1000 by 2007.-Spread to CVD/Asthma.

Our Challenges:


-The Future…*Spread to 3 new sites.*Spread to 3 new providers.*Spread to CVD/Asthma.*Increase funding.*Community health partnership.*Nutritionist.*Establishment of Diabetic Clinic.*Eye care.


Diabetes Collaborative Team Members: Ola Smith- CEO Alta Lowman, DM-Educator Tanya Hutchinson-PA . Delores Johnson-PR Agent. Bonnie Lee-SCS. Leticia Fernandez-DDC Patricia Durrance-PA/DDC Roberto Garcia, MD.-Team Leader


Final Message:

“With federally funded health centers having fully embraced the care model for disparities…this has become arguably the largest, most important, health care quality improvement initiative in the country. It is exactly what the health care system needs right now.”

Tracy Orleans, PhD-Senior scientist at Robert Wood Johnson Foundation.

diabetes collaborative disparity

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