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California Chronic Care Learning Communities Initiative Collaborative

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:.

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California Chronic Care Learning Communities Initiative Collaborative

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

  2. Collaborative Team Members

  3. Contra Costa Health ServicesRichmond Health Center

  4. 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…”

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

  6. . Community Health System Organization of Health Care Resources and Policies Case management coordination with our Health Plan • Kaiser • Laotian community Informed, Activated Patient Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes

  7. Informed, Activated Patient Prepared Practice Team Productive Interactions Our educational approach changed to support patient self-management skills... The Registry allows us to proactively reach out to patients and make sure they get all the care they need…..

  8. 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.

  9. Clinical Outcomes

  10. Process Outcomes

  11. 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.

  12. 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…

  13. Keys to Sustaining and Spreading Our Chronic Care Improvements

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