California Chronic Care California Chronic Care Learning Communities Learning Communities

InitiativeInitiative(CCLC)(CCLC)

Funded by the California HealthCare Foundation

Building a Shared Vision Building a Shared Vision for Chronic Care Improvementfor Chronic Care Improvement

For diabetic patients served by nine public hospital clinics, our goal is to:

• Improve care processes• Decrease complications• Reduce cardiovascular risk

What do we want What do we want toto achieve? achieve?

In 9 months, the CCLC aims to achieve breakthrough improvement in:

• Control of clinical risk factors

• Use data and information systems to support pro-active care

• Improve use of self-management support strategies by patients and providers

Where are we starting from?Where are we starting from?

The U.S. health care system does a poor job of caring for patients

with chronic conditions

Disturbing factsDisturbing facts

• Half of patients hospitalized with congestive heart failure are readmitted within 90 days.

• 63% with diabetes have HbA1c levels > 7.0%.

• 66% hypertensives have BP out of control.

Ni et al. Arch Intern Med 1998;158;231. Saydah et al. JAMA 2004;291:335. JNC 7. JAMA 2003;289:2560.

Californians with chronic illnesses vs.Californians with chronic illnesses vs.Californians receiving good careCalifornians receiving good care

(in millions)

0 1 2 3 4 5 6

HBP

Diabetes People receiving good care

People in California

Most chronic care is primary careMost chronic care is primary carePercentage of Office Visits Accordingto Physician Specialty, By Primary Dx

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

HTN DM CHD COPD

Generalist

Specialist

Source: L Green, Analysis of 1996 Natl Amb Med Care Survey

Where are we starting from at Where are we starting from at the nine CCLC public clinics?the nine CCLC public clinics?

• 13,167 diabetic pts.

• Some clinics report > 20% HbA1c >9

• 24% of pts. have high cholesterol

• 43% of pts. w/hypertension

• 24% of pts. obese

• 10% of pts. smoke

Where are we starting from at Where are we starting from at the nine CCLC public clinics?the nine CCLC public clinics?• Fragmented care

• Inadequate information systems

• Lack of pt. self-mgmt.

• Irregular testing/exams

• Ccare mgmt. left to busy PCPs

• Low ability to stratify pts. by risk

We know what is possibleWe know what is possible

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Improved Outcomes

Chronic Care ModelChronic Care Model

Ocean Park Health Center, SF Ocean Park Health Center, SF Community Health NetworkCommunity Health Network

Participated in California Quality Improvement Collaborative and, in 6 months, achievements include:

• ↑in % pts. w/LDL <100 from 38% to 53%

• ↑in % pts. w/controlled BP from 36% to 53%

• ↑ in foot exams from 12% to 65%

• ↑in self-mgmt. goal setting from 0% to 40%

Bureau of Primary Health Bureau of Primary Health Care Health Disparities Care Health Disparities

CollaborativesCollaboratives

• 23 community health centers achieved

↓HbA1c levels by 1%

Other public hospital clinics have Other public hospital clinics have achieved impressive outcomesachieved impressive outcomes

Santa Clara Valley Medical Center’s Chronic Care Management Program, in 2 years:• ↓HbA1c levels by 1%

Edward R. Roybal Comprehensive Health Center, of the LA County DHS, in 6 months:

• ↓avg. LDL from 115 to 101• Avg. LDL held at 105 after 1 yr.

Other public hospital clinics have Other public hospital clinics have achieved impressive outcomesachieved impressive outcomes

San Mateo Medical Center

Diabetes Outpatient Education Program

• ↓% pts. w/HbA1c >8 from 52-54% to 18-20%

ChallengesChallenges

Financial instability of public hospitals and health systems

“The health care safety net is unraveling fast precisely when more families are falling into it.”

San Francisco Chronicle December 29, 2002

Other challenges to improving chronic Other challenges to improving chronic care in public hospitals/health systemscare in public hospitals/health systems

• No reimbursement for non-physician care• Inadequate information systems• Chaotic, overstressed primary care clinics• Multiple patient languages and few interpreters• Low health literacy• Difficulty changing job descriptions of clinic

staff• Delivery system geared toward acute illness

Strengths: Why changing chronic Strengths: Why changing chronic care in public hospital systems will care in public hospital systems will

make a differencemake a difference

• Health disparities: patient population is 78% people of color, predominantly low-income

• Training next generation of health care professionals

• Comprehensive systems of care: potential to improve along continuum of care

Facilitators for improving chronic care Facilitators for improving chronic care in public hospitals/health systemsin public hospitals/health systems

• Leadership/champions• Culture of “doing the right thing”• Why do some organizations perform better

than others? Virtually every study examining this question gives two reasons:– Leadership– Culture

• Good leadership and a quality-oriented culture enable organizations to overcome the barriers

“An impressive group of individuals throughout California have made major strides -- though limited in the proportion of the safety net population reached -- in improving chronic care. These individuals are the founders of a larger movement for chronic care improvement in California’s

safety net.” Examining Chronic Care in

California’s Safety Net

www.chcf.org

CCLCCCLC(9-12 months time frame)(9-12 months time frame)

Select Topic

(develop mission)

Planning Group

Develop Framework & Changes

Participants (9 teams)

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Supports

Email Visits

Phone Assessments

Monthly Team Reports

Congress,

Guides,

Publications

etc.

A D

P

SExpert Meeting

Learning Session I AgendaLearning Session I Agenda

Today: Get ideas!

Tomorrow: Plan changes!