West Central Cluster Summit Moving Ahead with Spread

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West Central Cluster SummitMoving Ahead with
Spread

• Cardiovascular Collaborative
• November 8 10, 2004
• Dallas, TX

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La Casa Family Health Center

• Location Portales, New Mexico
• Population Served 4,664
• Total Population 18,018
• Four Clinic Sites Portales, Clovis, Roswell and
  Hondo, New Mexico
• Cardiovascular Population
• Includes migrant, homeless, rural, urban,
  and dental

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Aim Statement
The aim of La Casa Family Health Centers
Cardiovascular Collaborative is to improve the
care of our cardiovascular patients through the
redesign of our system of care by implementing
the
Care Model accomplished by
developing patient self management
goals, decision support, and delivery
system design.
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Team Members

• Core Team
• Maxsimo Torres, MD, Chief Medical Director
• Carmen Pacheco, Director of Operations
• Rhonda Rivera, LPN
• Belinda Lujan, Team Leader, Patient Advocate
• Yvonne Armijo, CPhT
• Expanded Team
• Debra Herman, Pharmacist Clinician
• Mario Trance, MD, Clinic Director, Clovis
• Monem Gillan, MD Clinic Director, Roswell
• Judy Cox, RD
• Team Leader Key Contact
• Freda King, [phone]
• fking_at_lacasahealth.com

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History

• La Casa de Buena Salud was established in 1970
• A group of concerned women dedicated to address
  the lack of accessibility and affordability of
  prenatal care services in Portales, NM
• Operations from a tiny two-bedroom home
• Received official documents as a non-profit
  organization in 1974
• Received a 63,000 grant from the Campaign for
  Human Development United Catholic Conference in
  1976
• In August 1977, La Casa received the first grant
  from the Department of Health Education and
  Welfare, known today as
  the Department of Health and Human Services
• Between 1994 - 2001, La Casa has expanded
  healthcare services to four
  counties, acquiring
  18,000 patients and generating over 55,000
  patient visits

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Look How Far Weve Come

• THEN
• Two-bedroom house located in Portales, New Mexico
• One family practice physician
• Five employees administering the clinic
• 1,000 patients seen in the first year
• Patients were seen on a first come first serve
  basis
• All information kept in charts in alphabetical
  order by patient name
• NOW
• Four clinics located in Roosevelt, Curry, Chavez,
  and Lincoln county
• 16 providers specializing in various medical
  fields
• Dental clinic added
• Approximately 100 employees
• Generate over 55,000 patient visits annually
• Fully integrated appointment system
• Information transmitted via computers,
  
  hand-held wireless PCs, and walkie-talkies

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La Casa de Buena Salud, 1970
Portales, New Mexico 2004
Roswell, New Mexico 2004
Clovis, New Mexico 2004
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Spreading the Collaborative Movement

• Diabetes Collaborative begin July 2003, La Casa
  Family Health Center, Portales, New Mexico
• Core focus of the collaborative were diabetic
  patients
• Currently, Cardiovascular Collaborative in
  progress
• La Casa has diabetic registry of 907 patients,
  112 have now
  become part of our cardiovascular
  collaborative

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National Key Measures
112 of the 907 DM patients have now become part
of the cardiovascular collaborative
54.5 of the cardiovascular registry patients
have had a HBA1c.
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National Key Measures
57.1 of the cardiovascular registry have self
management goals.
90.7 of the cardiovascular registry are on ACEs.
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National Key Measures
58.6 of the cardiovascular registry have a
BPlt140/90
.
7.0 is the average HBA1c for our cardiovascular
registry.
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Optional Key Measures
63.9 of the cardiovascular registry had an
LDLlt100
Other Key Measures for the Cardiovascular
Registry

• 66.1 of the patients had 2 blood pressure
  checks in the last year
• 76.8 of the patients had a fasting lipid
  panel profile documented
• 66.7 of the patients use ASA or other
  Antithrombotic Agent
• 9.8 of the patients use a Beta Blocker

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Best Practices

• Patient education and awareness regarding their
  disease and treatment
• The buy-in of providers, support staff, CEO, and
  Board of Directors.
• Utilizing the internal incentive plans for
  meeting collaborative goals
• Providing PECS registry and summary reports to
  all providers and Board of Directors on a monthly
  basis
• Dietician on staff, conducting free support
  meetings for patients and public
• Pharmacy assistance by providing medications
  through Patient
  Assistance Programs, such as Sharing the Care

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Lessons Learned

• The importance of the buy-in from providers,
  support staff, CEO, and the Board of Directors
• Importance of PECS data to shape the providers
  work behavior
• Importance of using PECS system-wide
• Importance of involving patients
  in management and treatment
  of their
  disease

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Challenges To Date

• Self Management
• Patient motivation in achieving goals set
• Decision Support
• Providing timely feedback to providers
• Providing in-services to staff
• Referring for multidisciplinary care (i.e.
  pharmacy, dental, podiatrist, ophthalmologist,
  cardiologist, etc.)
• Community
• Developing partnerships that are consistent with
  area organizations missions
• Clinical Information System
• Having an IS person on staff
• Accessing and entering information at time of
  visit
• Organization of healthcare
• Staff participation
• Overall
• Consistency and motivation

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Next Steps

• Populating the cardiovascular registry
• PECS training for all key staff
• Develop a cardiovascular encounter tool
• Develop a self-management tool for
  cardiovascular patients

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A Story To Share, Our Patient
Mr. Ronald Shirley is a firm believer in the
Diabetes Collaborative and the care he receives
at La Casa Family Health Center. With the aide of
his doctor, the support staff and the Diabetes
Collaborative, he was able to lower his HbA1c
from 8.8 to 5.9. A much healthier and happy
person, Mr. Shirley has lost over 25 pounds
because of his commitment to exercise and dietary
changes. Three years ago, Mr. Shirley was
diagnosed with diabetes. With the components of
the collaborative and support he has been able to
keep his diabetes under control and adapt to his
new lifestyle. Mr. Shirley states that his
strongest tool in understanding and managing his
diabetes was achieving his self-management goals.
As a dedicated patient,
Mr. Shirley participated in
every aspect of the self management
goals. Today, Mr.
Shirley is concerned about his high
cholesterol. Because of
the strides and success he received
from the Diabetes
Collaborative, he is enthusiastic in
participating in the
Cardiovascular Collaborative.
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A Story To Share, Our Organization
MISSION
The Mission of La Casa Family Health Center is to
provide evidenced based quality primary care for
the entire family, with emphasis on the medically
underserved in southeastern New Mexico. With
the help of the Diabetes Collaborative, we are
able to achieve our mission. We have the ability
to gather patient data and track their progress.
The collaborative has enabled us to provide
exemplary care to our entire diabetic population
and fulfill our organization's mission.
DIABETES COLLABORATIVE