VALLEY COMMUNITY HEALTH CENTERS

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VALLEY COMMUNITY HEALTH CENTERS
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Team
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Background Information
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Team Information

• Team meets weekly (or roughly that)
• Select small PDSA cycles
• Review previous cycle and revise
• Spread change when ready
• Decisions are made by the team

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The Chronic Care Model
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Organization of Health Care

• How are the Collaboratives supported by
  leadership? CFO is team leader, CEO DM team
  leader, Board receives monthly reports.
• Who does the day-to-day leadership for continued
  clinical improvements? CMO/Provider Champion, CEO
  and CFO
• Are the Collaboratives part of your Quality
  Improvement program? Business plan? Performance
  Improvement program? YES!

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Dashboard
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Dashboard
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Organization of Health Care

• How are the Collaboratives supported by
  leadership? CFO is team leader, CEO former team
  leader, Board receives monthly reports.
• Who does the day-to-day leadership for continued
  clinical improvements? CMO/Provider Champion, CEO
  and CFO
• Are the Collaboratives part of your Quality
  Improvement program? Business plan? Performance
  Improvement program? YES!

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Decision Support

• Do you use evidence-based standing
  orders/guidelines? YES
• How do you educate your staff on the guidelines?
  Staff meetings, graphs posted monthly, HDC is
  part of orientation
• How do you educate your patients on the
  guidelines? Self-management, copies of flow
  sheets contain guidelines, educational material.

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Delivery System Design

• Protocols in place for staff role/duties/tasks
  during pt. visit? Folders, Nurse addresses SMG,
  Provider addresses SMG, Flow Sheet
• Proactive staff, not reactive staff? Proactive
• Who does follow-up? Case management? Provider
  team
• How do you meet patients special needs? Max-pack
  visit, weight management program and educational
  materials
• Do you do group visits? NO
• Any work flow studies at your center? Access
  and scheduling, filing and chart order,
  re-appointments

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Clinical Information System

• How do you use your data? Drill-downs for target
  areas, Continuous process improvement
• How do you do patient recalls? Reappointments at
  end of visit, PECS recalls based on drill downs
• How do you do handle data entry? One person does
  data entry needs improvement
• How do you prompt providers (PECS sheet or
  Reminder sheet)? Flow/Reminder sheet, symbols on
  outside of chart Purple foot for DM, Red Heart
  for CVD

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Self-Management

• How do you help the pt. set a goal? Flow sheet
  and educational packet
• What tools do you use? Self-management form and
  educational packet
• How do you follow-up and monitor goals? At next
  visit in relationship to lab values and weight
• Do you use community resources to achieve goals?
  Self Management Enforcement.

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Guido the Enforcer
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Community

• Do you have community partners to help with
  medication costs? Clinical Resource Coordinator.
• Education? DM Educator on site.
• Materials? Handout Packet.
• Have you been awarded any grants? NO

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Cardiovascular

• National Goal CVD
• BP in control 50
• Annual fasting lipid panel 80
• LDL treated to goal 60

• Your clinic
• 61
• 88
• 70

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Diabetes Measures

• National Goal
• Average HbA1C 7.0
• At least 2 HbA1C in the last 12 months (gt90 days
  apart) 90
• Self-Management goal in last 12 mo. 70

• Your Clinic
• 6.4
• 72
• 71

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Showcase your most successful graph from the
measures graph template data report
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Showcase your most challenging graph from the
measures graph template data report
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Questions from the audience?