Using the Chronic Care Model and the Model for Improvement, the G. A. Carmichael Family Health Center (Canton, Mississippi, USA) is making inroads against the growing epidemics of obesity and diabetes in their community.

The G. A. Carmichael Family Health Center (GACFHC), which serves three rural counties in Mississippi, has been offering clinical services since 1972. But, according to Janice E. Bacon, MD, Clinical Services Director, it wasn’t until the center became a participant in the Bureau of Primary Health Care Health Disparities Collaboratives in 1999 that “we learned how to put our processes together in one consistent format.”

GACFHC has a user base of nearly 23,000 patients, 96 percent of whom are African-American. The number of Hispanic patients has increased more than 200 percent in 18 months. Forty percent of the center’s patients are uninsured and in the self-pay (sliding fee) category.

Because obesity and diabetes are at epidemic levels in Mississippi, GACFHC decided to tackle these issues first. The center entered into a 13-month program used to train community health centers in the Chronic Care Model and the Model for Improvement, based on rapid-cycle testing (using the Plan-Do-Study-Act cycle) and change.

The baseline data GACFHC collected were alarming: the average hemoglobin A1c in its population was 13.8 percent. This figure, combined with information about patients’ behavior, diet, and lifestyle, provided the impetus for the GACFHC to create a diabetes team. The team used the Collaborative Learning Sessions and the Model for Improvement to establish the following goals:

• First, redesign clinical practice so that patients with diabetes would lower their hemoglobin A1c to less than 8.0; patients unable to achieve that goal would lower their hemoglobin A1c by an average of 1 percent.
• Next, have patients in the first group lower their hemoglobin A1c to less than 7.5; those with values greater than 8.0 would lower their hemoglobin A1c by an average of 1 percent.

At the clinic level, GACFHC focused on four components of the Chronic Care Model: self-management support, delivery system design, decision support, and clinical information system.

• Self-management support is achieved through group educational sessions, held on Saturdays; dental self-management goals that are incorporated into office visits; and a self-management contract with goals set for each patient. These goals, formulated by mutual consent between patient and provider, are set to achieve desirable outcomes in two areas.
• Delivery system design includes advance planning for patient visits, based upon the patient’s current needs. This planning allows patients to meet with primary care providers and other team members, including dentists, nurses, and medical and nursing assistants. Further, specialists in nephrology, urology, and cardiology are available on a rotating schedule.
• Decision support is addressed by integrating training and updating for medical, dental, and nursing providers on evidence-based guidelines for diabetes care. The diabetes physician champion, Dr. Debra Rice, devised an acronym for diabetes to capture the key components of the guidelines. This acronym is included in flow sheets and self-management contracts, and is posted as public reminders in the clinic:
  • D-Dental, Diet
  • I-Immunizations, Insurance status
  • A-Albumin screening, ACE/ARB usage, Anti-coagulation therapy, Always take medications
  • B-Blood work (hemoglobin A1c, lipid panels), Blood pressure
  • E-Eye care
  • T-Tobacco usage, Teeth, Triglycerides
  • E-Exam feet, Exercise
  • S-Self-management, Statins, Smoking status
• The clinical information system component is centered on a registry that organizes patient and population data to facilitate care. The ability to provide hemoglobin A1c data over time has been a very powerful tool, enabling the center to plan visits based on registry data and to develop proactive care plans.

Dr. Bacon says using the Chronic Care Model and the Model for Improvement is a terrific way to get an agency “out of the accepted modes of doing business.” Further, the models “get the staff energized” and empower staff members to break out of traditional roles. For example, a nursing assistant, whose job was previously limited to taking vital signs, now leads a team. The telephone operators now take the lead in a campaign to contact patients who haven’t been seen in a while. With these new tasks and new roles for established staff members, it’s not difficult to see how, for this clinic, it isn’t just business as usual any more.