1.better understand the national t/ta · 2017-11-30 · 1.better understand the national t/ta...
TRANSCRIPT
1. BetterunderstandthenationalT/TAeffortstosupporthealthcentersinaddressingdiabetes
2. GaininsightonimportantlessonslearnedfromthepreviousNationalDiabetesCollaborativework
LearningObjectives:
About AAPCHO• The Association of Asian Pacific Community Health
Organizations (AAPCHO) was formed in 1987• National association of 35 community health
organizations serving Asian Americans, Native Hawaiians, and other Pacific Islanders (AA&NHPIs)• Dedicated to improving the health status and access for
these medically underserved communities• BPHC funded NCA to provide T/TA to AA&NHPI
serving health centers
“Tobeaforceforhealthjusticeforthemobilepoor”
Training&Technical
AssistanceServices
ContinuityofCare
ViolencePrevention
EnvironmentalandOccupational
Health
ClinicalExpertise
Migrants,Mobile
Patients,OtherVulnerableWorkers
Clinicians
•Healtheducators•Nurses•Primarycareproviders•Dentists•Socialworkers•CHWs•Outreachworkers•Medicalassistants
FederallyfundedMigrant
&Community
HealthCenters
Stateandlocalhealth
departments
MCN’sprimaryconstituents
Participating NCAs in Special and Vulnerable Populations Diabetes Task Force• Association of Asian Pacific Community
Health Organizations (AAPCHO)• Corporation for Supportive Housing
(CSH) • Farmworker Justice (FJ)• Health Outreach Partners (HOP)• Migrant Clinicians Network (MCN)• MHP Salud• National Association for Community
Health Center (NACHC)• National Center for Farmworker Health
(NCFH)
• National Center for Health in Public Housing (NCHPC)
• National Center for Equitable Care for the Elderly (ECE)
• National Health Care for the Homeless Council (NHCHC)
• National LGBT Health Education Center• National Network for Oral Health
Access (NNOHA)• National Nurse-Led Care Consortium
(NNLCC)• School-Based Health Alliance (SBHA)
Housekeeping
Questions and Comments
• We will address questions and comments at the end of the webinar
• Please enter your questions and comments in the Question field
Webinar Recording
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2017-2020HRSAFocusonDiabetes
HRSAFundedDiabetesActivities2017-2018
Whatisyourexperiencewiththehealthdisparitiescollaboratives?
Whatwerethecollaboratives?
Notabandaidorcookbookapproach
Qualityimprovement
model
Redesignofprocessestoimprovedeliveryof
care
Standardsofcare- quality
ofcare
Nationallybenchmarkedindicators
KeyElements
Changeprimaryhealthcarepractices(clinical,clericalandadministrative)inorderto…
Improvethehealthcareprovidedtoeveryoneandto…
Eliminatehealthdisparities.
Qualityimprovementinitiativeintegrating:
Deliverysystemsdesign
Organizationofhealthcare
Clinicalinformationsystems
Communityresourcesandpolicies
Self-managementprinciples
Decisionsupport
Nottime-limited
Partners in the
Collaborative
All Health Centers
National Cooperative Agreements
National Health Service Corp
Programs
FQHC look-alikes
BPHC
CDC
Institute for Healthcare
Improvement (IHI)
CommunityResourcesandPolicies
IdentifyCommunityResources
Makepatientsawareofcommunityresourcesandmakecommunityresources
easilyaccessible
Participate(collaborate)withcommunityagencies
Assesstheneedsofthe
community
Areyouincludedinyourannualbusinessplan/healthcareplan(federalgrant)and
intheorganization’sstrategicplan?
Collaborativegoalsincorporatedinthemission
andvisionstatements
Performanceimprovementmodelfortheorganization
Seniorleadershipcommitment- CEO,Medical
Director,othermanagement/leadership
levels
Performanceappraisalsandjobdescriptions
HealthSystemOrganization
Evidence-basedguidelinesintegratedintoclinicalpractice• ADAguidelinesforcare• footexams• 2A1c’s>3months<12monthsapart• A1clessthan8• annualretinalexam• lipids• bp<130/80
DecisionSupport
ProtocolsforDiabetesCare
Howdoyouintegrate
generalistsandspecialistscare?
(referrals,feedback)
Howdoyougetbuy-infromyourprovidersforfollowing
guidelinesandmaking
appropriatereferrals?
DecisionSupport
Proactive,wellpatientdiabetesvisitsinsteadofcrisismanagementand
sick/acutevisits
Redesignpatientvisittointegrateteamcare,betterpatientflow,betterqualityofcare
• nutritionist• dental• podiatrist• officestaff• nurses•MAs• frontofficestaff• provider• outreachworkers(CHWs)
Teamconceptofcare
ClinicalInformationSystems
Identifyyourpopulationoffocusü Targetpopulationü Howdoyoufind250.xxpatients
Thiswasarealissueinlate1990sbeforebroadEHRimplementation
Registry- DEMS/CVDEMS/PECSVisitnotes,queries,reportsAreyoudoinganythingwiththedata?Doyoudatausedforindividualizedcareplanning,patientrecall,etc?
PaperChartsareCIS,too!Documentationofdeliveryofevidenced-basedcare
SelfManagementSupport
Self-managementcontracts
Thepatientisaccountablefordiseasemanagementand
healthoutcomes.
Educationincreasesthepatientsabilitytomake
informeddecisionsaboutthecarereceivedandhealth
outcomes.
Goalssetbythepatient
Self-management
support
Labs,etc.provide
feedbacktothepatient
Peer/supportgroups(CHWshugehelp)
Behaviorchangeprograms(smoking,
weightcontrol)
Empowerthepatienttotalk/ask
questionsoftheprovider
Informed,activatedpatient
••Decreasedwaittimes••Patientshave2A1cs••Patientshaveappropriatereferrals••Patientshavedocumentedfootchecks
FunctionalOutcomes
••PatientA1cislessthan8••Bloodpressureis<130/80••PatienttakesASA••Patientstopssmoking
ClinicalOutcomes
Diabetes1:• 88healthcentersparticipatedinthefirstDiabetesCollaborative
• 16,000peoplewithdiabetesenrolledinregistries
Diabetes2• 115healthcentersparticipated
• 40healthcentersandschool-basedhealthcentersparticipateintheAsthmaandDepressionCollaboratives.
FinalNumbers????
Transformpractice:Models• ChronicCareModel:apopulation-basedmodelthat
reliesonknowingwhichpatientsneedcare,assuringthattheyreceiveknowledge-basedcareandactivelyaidsthemtoparticipateintheirowncare
• ImprovementModel:Howtotestchangesinasystemofcareinafastandefficientway,ensuresthatchangesareanimprovement,andexpandthechangesthroughoutthepractice.
• LearningModel:Aperformance-basedlearningmethodthatsupportsacommunityoflearnerstoapply,adapt,share,andgenerateknowledge,andspreadpositivechange.
Select Topic
Planning Group
Identify Change
Concepts
Participants
Pre-work
LS 1
P
S A D
P
S A D
LS 3
LS 2
Supports E-mail Visits Phone Assessments Senior Leader Reports
Time for setting aims, allocating resources, preparing baseline data leading to the first 2 day meeting.
Action period 1: Adapt and test the ideas for improved
system of care
Action period 2: further develop the
system of care at the pilot site and spread the
system to other sites
Congress & beyond
Phase 1
Phase21. SustainandSpread2. Continuedreportingandprogresstoward
nationalgoals3. Integrationofmodelsintotheorganizational
structure4. Increasingregistrysize5. Continuedsupportandinteraction
CollaborativesAreasofFocus
• Diabetes:334HealthCenters
• Cardiovascular:54HealthCenters
• Asthma:60HealthCenters
• Depression:53HealthCenters
• Cancerpilot:12HealthCenters
• Preventionpilots:10HealthCenters
Outcomesataglance….
Almost60,000patientsinclinicalMIStotrack/managecare
Majorimprovementinglucosecontrol
Improvedbloodpressurecontrol
Appropriateuseofdrugsforasthma
Highratesoffollow-upandimprovedsymptomsfordepression
Increaseinpatientself-management
NumberofHealthCenterPatients*inClinicalInformationSystems
*FromDiabetesI,II,III,CVDI,andAsthmaII
54,815
0
10000
20000
30000
40000
50000
60000
DM1(51%ofteamsreporting) DM2(61%ofteamsreporting)DM3(94%ofteamswithCVD) AsthmaIICVD(94%ofteamscombinedwithDM3) TOTAL
ImprovedOutcomes
Year1• StartedwithaverageHGBA1Cof9.8
• Endedwith8.0
Year2• Endedwith7.8
Year3• Endedwith7.4average
Doyouknowthepercentageofyourhealthcenter’sdiabeticpatients
whoseHA1cis>9?
üIn2016thepercentageofdiabetichealthcenterpatientswithanA1c>9.0was32.1% andhasnotgonebelow30%inthelastfouryears.
ü6.5% ofhealthcentersin2016wereatorbelowtheHealthPeople2020goalof16.2%ofdiabeticpatientswithanA1cbelow9.0.
ComparativeDatainthePrivateSector
EthnicDisparitiesinDiabeticComplicationsinanInsuredPopulationJAMA,May15,2002—Vol.287,No.19
HbA1cLevel,mean(SD)Black Asian Latino White8.9(1.8) 8.7 (1.8) 8.8(2.0) 8.4(1.8)
Thatsameyear,healthcenterdiabeticpatientsinthecollaborativeaveragedaHA1cof7.4.
21 Years of innovation
1Health Network Enrollment Criteria
Patient is:• Already mobile OR• Likely to move
2 Patient is in need of a clinic for follow-up of ANY health condition
3 Clinic Must:• Complete Enrollment Registration• Have patient sign Consent/Send• Send Medical Records
Contacts patients on a scheduled basis(monthly for TB patients)
Contacts clinics monthly
Assists patients in locating clinics for services and resources
Reports back to the enrolling clinic and notifies them of outcomes
2,951 total clinics in U.S. and over 111 countries
Over 11,461 total HN
enrollments
“Fernando” is a 56 year old migrant farmworker diagnosed with diabetes at age 49. He traveled each year from South Texas to Minnesota or “wherever I can find work”
Enrolled in Health Network 8/02
10/02
1/03
10/03
11/05
12/06
6/07
10/074/09
Fernando was closed out of Health Network in 2013 because he said that he was no longer migrating.
Over the ten years he was enrolled, Health Network made 46 clinic contacts, 124patient contacts, transferred medical records 9 times to 6different clinics.
6.00%
7.00%
8.00%
9.00%
10.00%
11.00%
12.00%
13.00%
14.00%
15.00%6/1/2002
10/1/2002
2/1/2003
6/1/2003
10/1/2003
2/1/2004
6/1/2004
10/1/2004
2/1/2005
6/1/2005
10/1/2005
2/1/2006
6/1/2006
10/1/2006
2/1/2007
6/1/2007
10/1/2007
2/1/2008
6/1/2008
10/1/2008
2/1/2009
6/1/2009
10/1/2009
2/1/2010
6/1/2010
10/1/2010
2/1/2011
6/1/2011
10/1/2011
Fernando’sHBA1cWhileEnrolledinHealthNetwork
HealthNetworkIMPACT• Bridgebetweenpatientsandtheirproviders• Fewerpatientslosttofollowup• Higher%ofpatientscompletingtreatment• Treatmentcompletionreports• Improvedpatientparticipation
PearlsfromtheCollaboratives
Needtonotonlyobtain
cleanaccuratedatabut
ANALYSEANDACTontheresults
Focus added effort/resources on individuals with poor
diabetic control
Remember this is a “team sport” each individual has an important role to play
Self-managementisyourmostcosteffectiveandmostpowerfultoolinyourclinicaltoolbox
Questions?
Contact
JillianHopewell,MPA,MADirectorofEducationand
Communication(512)579-4530
EdZuroweste,MDCo-ChiefMedicalOfficer
(814)[email protected]
www.migrantclinician.org
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Thank You!For more information, please visit our websites:•www.aapcho.org/•http://www.migrantclinician.org/
Or contact:•Jillian Hopewell: [email protected]•Ed Zuroweste: [email protected] •Tuyen Tran: [email protected]