Community Health Partners

1
Community Health Partners

• West Central Cluster Summit
• Moving Ahead With Spread
• November 8-10, 2004
• Dallas, TX

2
Community Health Partners Diabetes 2, CVD 2,
Depression 2

• Community Health Partners began offering sliding
  fee scale services in Park County in early 1998.
  The organization now manages four clinic sites
  (Park (1) and Gallatin County(3), 27/90 miles
  apart), serving a combined population of 77,000
  individuals (target population at 200 and below
  poverty approximately 30,000 people). During
  its six years of existence, Community Health
  Partners has expanded its offering of services.
  These include comprehensive primary medical care,
  extensive medical referrals and mental health
  referrals, Title X family planning services
  (through a partnership), on-site obstetric
  services (through a contractual arrangement),
  patient assistance/340b pharmacy, behavioral
  health and a full-fledged adult/GED and family
  literacy program.

3
The Mission/Aim

• To enhance community health
• and well-being, through
• Innovative programming
• Strong partnerships
• Improved outcomes

The Vision 100 Access, 0 Disparity
4
Team Members

• Laurie Francis ED Erich Pessl PC
• Amy Berghold TL Maggie Murphy IS
• Colleen Nelson Barb
  Marshall
• Kim Quesenberry Kara
  Krietlow TL
• Mona Stenberg Cassie Burns
• Libby Fredrickson Eileen Ralicke
• Paula Guay Buck
  Taylor
• Team Leader Key Contact Info _at_ CHP Amy
  Berghold, 406-222-1111 ext 126
  e-mail aberghold_at_chphealth.org Team Leader Key
  Contact Info _at_ GCC Kara Krietlow, 406-585-1360
  ext 21 e-mail kkrietlow_at_chphealth.org

5
How it all Started.

• Opened doors in 1998 one site in rural Montana
• Always devoted to continuous quality improvement,
  emphasis on data driven changes, and excellence
• Entered first collaborative in 1999 Diabetes
  collaborative.
• Initial population of focus was 12-15 patients

6
CHP History - A Snapshot of Programs
All health disparities, mental health,
pharmacy, Full GCC, Even Start 37 FTEs
CHP starts, Medical, Diab. Collab, 8 FTEs
General expansion, 19 FTEs
1999
1998
2000
2001
2002
2003
Provider time, dental starts, Collab. at GCC, 45
FTEs
Literacy begins, 14 FTEs
GCC joins, CVD collab., 21 FTEs
7
Spreading the Collaborative Movement
8
Spreading the Collaborative Movement cont
9
Diabetes
10
Diabetes cont
11
Depression
12
Depression cont
13
CVD
14
CVD cont
15
Best Practices

• Collaborative Team for all three disease meets
  monthly for 2 hrs
• Designated team leader and facilitator
• Established decision making method and norms for
  the group
• Team Responsibility guide used monthly
• Yearly Strategic Plan
• Reports monthly to All staff and Medical Staff
  meetings
• Motivational Interviewing Training and Sustaining
• Balance Score Card for Organization
• Algorithmic approach to all three diseases
• Self-Management
• Team Effectiveness training and Sustaining
• Communication Training and Sustaining
• Collaboratives are part of Community Health
  Partners Mission
• CQI
• Constantly evaluating the 5 critical factors to
  change
• Staff Buy-in integral part of system design
• Readiness for change
• Empowered, enthusiastic team
• Visible management support

16
Team Work
Great Teams are Learning Organizations Groups
of people who, over time, enhance their capacity
to create what they truly desire!
As new skills and abilities develop, The world we
see shifts. Growing Understanding of ourselves
and others Begin to listen to the whole.
Awareness and Sensibilities
Deep beliefs And assumptions Change with
experience Let go of hierarchical Organizational
world View in favor of far Greater latitude to
shape Our world.
Ability to reflect on assumptions and patterns of
behavior. Change because you want to, not because
you have to. See the whole from an organizational
perspective
Enduring Change
Skills and Capabilities
Attitudes and Beliefs
17
Facilitation of Group Process

• Team Member involvement
• Keeps the group focused and on track
• Help members hear what others have to say
• Take time to get everyone on board and reach an
  agreement
• Insure process clarity
• Progression towards the goal (s)

Shared Facilitator
Leader
18
Lessons Learned

• The need for clinic wide buy-in related to a
  greater involvement of coordination at the
  Gallatin site.
• The need for on site learning from organization
  wide PDSA cycles and establish relevant site
  specific CVD, Depression, and Diabetes protocols.
• The need to increase credibility and buy in to
  changes made at each site.
• We will have improved outcomes related to
  increased attention to all care model components
  and coordinator oversight
• Resources affect every aspect of the care model
  organization wide
• The need to develop numerous strong partnerships
  which are regarded as catalysts for change in the
  communities in which they are present in. All of
  the above partnerships greatly improve patient
  outcomes by improving expertise, enhancing access
  to laboratory testing, and providing supportive
  programming.
• Leadership precedes, parallels, learns from, and
  follows collaborative successes
• Constant learning and refinement is integral
• Strong relationships supported by ongoing
  communication create collaborative fiber
• Collaborative understanding permeates all clinic
  systems

19
Next Steps

• Refine protocols
• Continue to encourage complete buy-in
• Refine team functioning education,
  communication, facilitation training
• Spread to both clinics, all diseases
• Incorporate electronic medical records to
  facilitate care and adherence to protocols
• Maintain leadership commitment