Collaborative Leadership:

Wendy Jameson, Collaborative Director and Director, California Health Care Safety Net Institute
Tom Bodenheimer, MD, Collaborative Chair and Adjunct Professor, UCSF Department of Family and Community, San Francisco General Hospital
Angela Hovis, Improvement Advisor and Independent Consultant
Michael Hindmarsh, Collaborative Coach and Manager of Clinical Improvement, Improving Chronic Illness Care, McColl Institute for Healthcare Innovation, Group Health Cooperative Center for Health Studies

Team Leaders:

Robin Halprin, PHN, Eastmont Wellness Center, Alameda County Medical Center
Evan Seevak, MD, Information Systems Medical Director, Eastmont Wellness Center, Alameda County Medical Center
Dianne Sceranka, RN, Ambulatory Care Manager, Arrowhead Regional Medical Center
Kit Chan, RN, Chinatown Public Health Center
Kate Colwell, MD, Physician, Richmond Health Center Ambulatory Care Quality Improvement, Contra Costa Health Services
Laura McCarthy, FNP, Quality Improvement Coordinator, Potrero Hill Health Center, San Francisco Department of Public Health
Hali Hammer, MD, Medical Director Family Health Center, San Francisco General Hospital
Rob Fleming, Clinic Manager, 39th Avenue Clinics, San Mateo Medical Center
Patrick Kearns, MD, Director, Chronic Care Management Program Santa Clara Valley Medical Center
Marie Palazuelos, MD, Medical Director, Silver Avenue Family Health Center, San Francisco Department of Public Health

Key Faculty:
Lyn Berry, MD, Director, Diabetes Clinic Alameda County Medical Center
Lisa Johnson, MD, Medical Director for Quality Improvement for Community Primary Care Clinics, San Francisco Department of Public Health
Maren Pedersen, MD, Medical Director, Chronic Disease San Mateo Medical Center
David Ofman, MD

• Glycemic control
  • Decrease average HbA1c values to less than 7
  • Increase percent of patients with controlled HbA1c less than 7 to 60 percent
  • Increase HbA1c testing to 90 percent of patients
• Prevention of cardiovascular complications or risks
  • Decrease fasting LDL to less than 100 mg/dl for at least 70 percent of patients
  • Decrease blood pressure to less than 130/80 mmHg for at least 40 percent of patients
  • Increase ACE inhibitors or ARB medications to at least 75 percent of appropriate patient population OR
  • Increase use of Statins to at least 60 percent of appropriate patient population
• Self-management
  • Increase documentation of a self-management goal for at least 70 percent of patients

At the level of clinical practice, five areas (elements of the Chronic Care Model) influence the ability to deliver effective chronic illness care. These are self-management support, delivery system design, decision support, clinical information systems, and health care organization. These were the primary focus of the California Chronic Care Learning Communities Collaborative.

Self-management support: Empower and prepare patients to manage their health and health care

• Assist patients in developing self-management goals, using forms such as “My Action Plan” and personal diabetes health records.
• Follow up with phone calls to document success of each patient.
• Train other staff involved with patient to use the forms, check in with patient re: self-management support, and use forms, each time patient comes to clinic.
• Use effective self-management support strategies that include assessment, goal setting, action planning, problem solving, and follow-up.
• Have patients bring all medications to every visit.
• Offer and refer patients to community resources, such as farmer's market, support classes, yoga, etc.

Delivery system design: Assure the delivery of effective, efficient clinical care and self-management support

• Define roles and distribute tasks among team members (e.g., train medical assistants to collect blood pressure and weight and prepare patient for foot checks, and diabetes educators to check medications and if patient is currently on preventive care).
• Establish standing orders so nurses can order tests and make referrals to eye exam, podiatry, etc.
• Bring eye exam on-site to clinic.
• Conduct individual planned visits.
• Conduct group visits.
• Establish risk stratification system and refer complex patients to clinical case management services.
• Use diabetic flow sheets in medical record, produced by disease registry, as prompts for planned care.
• Use culturally appropriate educational materials and maximize use of interpreters when needed.

Decision support: Promote clinical care that is consistent with scientific evidence and patient preferences

• Use diabetes flow sheet as tool to ensure proper clinical practice is carried out.
• Update diabetes clinical guidelines and put them at the point of care.
• Integrate specialist expertise and primary care (e.g., by standardizing feedback to primary care doctors from specialists).
• Publish approved protocol for medication management and distribute to care managers. Test competency level before allowing care managers to adjust medications.
• Share evidence-based guidelines and information with patients to encourage their participation, through clinical staff informing patients and access via Internet.

Clinical information system: Organize patient and population data to facilitate efficient and effective care

• Establish a disease registry (most teams used CDEMS).
• Use lists generated by registry to identify patients that need closer follow up or are overdue for visit or other needed care.
• Use flow sheet generated by registry to prompt evaluation and ordering of required tests.
• Share information with patients and providers to coordinate care.
• Use monthly data on performance to identify and solve barriers and accelerate improvement.

Health care organization: Create a culture, organization and mechanisms that promote safe, high quality care

• Generate support and interest at highest levels of leadership by sharing results and facilitating peer interaction. 
• Use senior leader support to fix system-wide barriers, such as difficulty accessing eye and foot exams.
• Convene spread leaders to facilitate peer exchange of ideas, provide expert support for spread.
• Promote effective improvement strategies aimed at comprehensive system change.
• Develop agreements that facilitate care coordination within and across organizations (e.g., between primary and specialty care).

There were also community-based efforts, but the main focus was internal to the public hospital systems.

Although the final results will not be in until November 2005, this collaborative has achieved remarkable progress with their pilot populations in improvement of diabetes care processes and clinical outcomes in just 7 months (real improvement work did not start until February 2005).

• Five teams exhibit improvement in clinical outcomes, such are reduced HbA1c and LDL cholesterol.
• On average the teams have achieved self-management support with nearly 50 percent of their patient population, starting from zero. 
• Foot exams have increased dramatically as well, from less than 20 percent to 60 percent. 
• Three teams have achieved breakthrough results, including smoking cessation for 20 percent of pilot population (Santa Clara); decrease in average HbA1c from 8.2 to 7.8 (Richmond Health Center); and getting 80 percent of patients to document self-management goals (39th Avenue Clinic, San Mateo).

Lessons Learned:

• One way to get multiple, large, complex institutions involved in collaborative improvement work is to kick off with a great, inspiring speaker to talk about the gap in quality and set the vision, then look for those who have a spark and a lot of enthusiasm and get them involved early on recruiting others to join the collaborative.
• Having faculty who are practicing physicians from public hospital systems who have already gone through a chronic care collaborative was critical to this collaborative’s success.
• Structuring the collaborative to include institutions with similar structures and problems is both supportive and motivating for staff — this is definitely a strength of this collaborative.
• Success is quite dependent on involvement from senior leadership and this is often difficult to obtain.
• Information technology, while critical to success, is an enormous obstacle — from inadequate machinery, to very little support (technical and data entry), etc. More help with this — both physical and technical — would have been better.
• Collaboratives are a great way to light the spark with potential chronic care champions, and disseminate and share information. But also need to support the spread leaders going forward.
• Some teams at first thought it was not appropriate to try setting self-management goals with some of the diverse populations served at public hospital systems, and set their goals too low.  Many have now surpassed their original goal. So don’t underestimate the potential power of self-management support with a variety of cultural groups.
• Busy, understaffed public clinics, with many physician residents and part-time staff, have difficulty keeping regular team meetings. They came up with different ways of staying connected and moving forward, but in some cases progress suffered when regular team meetings did not happen.

Wendy Jameson, Collaborative Director
California Health Care Safety Net Institute
wjameson@caph.org

[Storyboard presentation at IHI's National Forum, December 2005]