Selected characteristics of patients in participating CHCs compared with those in the general state population () suggest that CHCs serve a more ethnically diverse population (18
) with a higher prevalence of uninsurance (19
). Interviewees were team leaders from all 17 CHCs, 2 provider champions, and 7 team members. Each component of the Chronic Care Model was represented in the findings ().
Characteristics of Patients at Community Health Centers Compared With Patients Statewide, Massachusetts Diabetes Health Disparities Collaborative, 2006
Themes of Activities, Massachusetts Diabetes Health Disparities Collaborative, 2006
Teams reported that their patients were more likely to set self-management goals as a result of the CHC's participation in the collaborative. Many reported that changing the practice philosophy at the CHC — specifically, recognizing that patients play a role in determining their health and can be empowered to control their disease — was necessary to achieve this success. Allowing patients to assume some responsibility for the management of their diabetes was a new approach for many teams:
The empowerment of people to do self-management goal setting, this was something that we were not aware of before [the collaborative began]. — CHC 16, team leader
Teams noted that helping patients set goals for self-management became a priority for the entire health care team at the CHC. They approached patients as a team, followed up with patients who had not yet set a goal, and met with patients before and after their clinic visit:
We introduced the topic to our patients. We called patients to discuss it. We discussed it at group visit meetings. We used [team members] to implement self-management goal setting with our patients. [Dr A] was very proactive in discussing self-management with her patients; [Dr B] wanted people to go home and think about it. The [medical assistant] would follow up with these patients via telephone and help them set goals. — CHC 16, team leader
Understanding and implementing clinical guidelines for diabetes emerged as a major theme under the decision support component of the Chronic Care Model. Teams agreed that structured learning sessions (three 2-day conferences organized by the League of Community Health Centers during the collaborative that provided CHCs opportunities to share best practices) were instrumental in updating care to be consistent with scientific evidence and patient preferences. Understanding guidelines provided the impetus to improving patient care:
Being involved in the collaborative has drastically improved the quality of care that our diabetic patients receive. When a diabetic patient comes in, we know what the standards are. We offer our patients more, such as group meetings, healthy choices, relationships. We have become involved in other initiatives, increased our knowledge, and are committed to the project. — CHC 16, team leader
Delivery system design
Teams noted that patients' language and literacy issues were a challenge to changing delivery system design. Strategies for addressing this challenge were recruiting multilingual staff, adapting and translating materials, redesigning educational handouts using a pictorial focus, and using interpreters.
Teams reported the need to expand the role of health care providers, particularly medical assistants and nurses, because provider champions had limited time to spend with patients. They suggested using PDSA cycles to identify strategies for role expansion or spreading the change in role to additional sites:
[PDSA cycles can be used] to expand staff roles and responsibilities, such as having the MAs [medical assistants] ask patients to remove shoes as a prompt for foot exam. — CHC 1, team leader
We have redesigned our system, training MAs to do finger sticks, point-of-service testing. We are considering this system redesign for our satellite site. — CHC 13, team leader
All of the CHC team members we interviewed recognized the importance of using a patient registry to review clinical outcomes and improve care. Depending on the CHC's information technology (IT) resources, teams used different methods to track patient outcomes. Each CHC created a registry of diabetic patients in its population of focus either via an electronic medical record or the Patient Electronic Care System (PECS), a widely used chronic disease registry. Producing regular reports with patient data generated interest from providers and others within the CHC:
In the first 6 months of the collaborative, when we saw our data, all our numbers were low. We recognized that we were not lab testing our patients, especially regarding HbA1c [hemoglobin A1c]. Our provider champion began sending his patients for labs, including HbA1c, microalbumins. We had never even done microalbumins before. Our medical director would give a report at provider meetings, and when the other providers began to see results they became more aggressive in treating their diabetic patients. — CHC 4, team leader
The patient registry also generated some negative feedback, for example, that it lacked IT support, that the PECS or electronic medical record was limited, and that extra resources were necessary to gather and enter data into the registry:
It is very important to have an IT person, a good IT system, and people who have knowledge about IT. We need to have more detailed discussions on mechanics of data collection prior to the project's startup. — CHC 14, team leader
Promoting buy-in and support was a major theme for the organization component and had 3 dominant subthemes: senior leadership, provider champions, and staff. Making changes in the CHC was perceived to be difficult without the endorsement of CHC leadership:
Senior leadership buy-in, such as the CEO, is very important, with an emphasis on getting this buy-in early on in the project. The best thing that happened was at the kickoff for the collaborative, CEOs attended. If you want to make changes, you need senior leadership to make it a requirement. — CHC 7, team leader
At some CHCs, the provider champion advocated for the team, soliciting additional resources and assistance:
We continue to struggle. Our provider champion went to senior management and has been able to add an additional member to our team 2 months ago, a medical assistant. We hope to have less problems as staff has increased. — CHC 10, team leader
Without an engaged and active provider champion, reorganization was more difficult. Similarly, educating staff about the collaborative can prevent resistance from non-team members.
Another dominant subtheme for success in the organization component was changing the organization's policies and procedures. Some teams said their members worked with human resources staff to modify job descriptions and responsibilities. In addition, some sites altered how all CHC patients are seen:
We have now made it policy that our diabetic patients have an HbA1c every 3 months, cholesterol annually, and microalbumin. We have also begun educating our patients to test [blood glucose] 2 hours after their biggest meal rather than testing in the morning only. — CHC 3, team leader
CHC teams reported that linking with the community sometimes required pooling resources by working with other agencies, including other CHCs:
We were involved in another grant where we were meeting with other CHCs. This allowed us to identify other resources and use these connections. — CHC 11, team leader
We grouped responses that did not fit into the Chronic Care Model components into a separate category. Additional themes for this category were staffing issues, time constraints, persistence, and administrative support from the League of Community Health Centers.
Staffing issues included staff turnover, loss, and a lack of staff to assume the additional responsibilities of the collaborative. An additional barrier was limited time available to meet regularly as a health care team or to generate reports required for the collaborative. These 2 major challenges, in addition to issues with the patient registry, were universally reported by teams as challenges to achieving success in the collaborative. Team members also said that persistence was necessary to achieve the collaborative's goals. Several team members expressed the need to "keep trying and not give up" despite the additional work generated by participating in the collaborative. Most teams reported that the assistance, support, and encouragement from the League of Community Health Centers facilitated success in the collaborative, particularly information provided at the learning sessions and the monthly feedback on reports by the league's quality initiatives manager.
CHC teams described the type and number of PDSA cycles completed, by Chronic Care Model component each month. The most common activities addressed delivery system design. The least common were related to community ().
Number of plan-do-study-act (PDSA) cycles reported by community health center teams, Massachusetts Diabetes Health Disparities Collaborative, 2006.
|Self-management||Decision Support||Delivery System Design||Clinical Information||Organization||Community|