CHASS HEALTH CENTER Community Health

1
CHASS HEALTH CENTERCommunity Health Social
Services Center, Inc.

• Diabetes Collaborative
• Learning Session 2
• May 12-14, 2005
• Atlanta, Georgia

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CHASS Health Center

• CHASS Center is a non-profit federally qualified
  health center which
• provides a wide range of services. These
  services include medical,
• dental, laboratory, pharmacy, nutritional
  counseling, referrals and
• other specialty services.
• Three Locations
• Southwest Detroit (Diabetes Collaborative Site)
• Midtown Detroit
• School Based Clinic
• Staff
• 8 Providers (3 MDs, 3 PAs, 2 NPs)
• Dentist
• Hygienist
• 2 Certified Diabetic Educators

• Pharmacist
• Nurses
• Social Workers
• Other Support Staff

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CHASS Health Center

• Supplemental Services
• Women, Infant Children (WIC)
• LA VIDA Domestic Violence Program
• REACH Detroit Partnership (CDC)
• Community Action Against Asthma (CAAA)
• Healthy Moms
• Population served
• 81,100 services provided annually
• Approximately 834 patients diagnosed with
  diabetes
• 21 African American, 5 Caucasian, 69 Hispanic,
  5 unidentified

4
Team Members
Team Leader Paula Mass, PAC, CDE 313-849-3920
pmass_at_chasscenter.org
Ricardo Guzman Executive Director
Dr. Felix Valbuena, Jr. Medical Director
Paula Mass, PAC , CDE Team Leader
Lorelei Claiborne, DDS Dentist
Sylvia Garcia Clinical/Tech Expert
Marylu Villarreal IS
Elva Rodriguez IS
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Aim statement

• CHASS will redesign its system of
• care to provide improved care for
• patients with diabetes,
• hypertension and dyslipidemia
• based on the Care Model.

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Population of Focus

• CHASS Centers population of focus will be
• all the patients who have diabetes,
• hypertension and dyslipidemia in Dr. Felix
• Valbuenas panel of patients. The initial
• size of this population will be
• approximately over 100 people. New
• Patients identified with diabetes,
• hypertension and dyslipidemia will be
• added to Dr. Valbuenas panel.

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Key Diabetes Measures

• At least 90 of our patients receiving at least 2
  HbA1cs at least three months apart within one
  year.
• An average HbA1c of lt7.0
• 70 of our patients will have documented
  self-management goals set in the past 12 months.

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Key Diabetes Measures

• At least 75 of our patients 55 years and older
  will have current prescriptions, ACE inhibitors
  or ARB medication
• At least 40 of our patients will have blood
  pressure lt130/80
• At least 70 of our patients will have a dental
  exam within 1 year.

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Key htn Measures

• At least 50 of our patients with HTN will have
  BP lt140/90 mmHg.
• At least 90 of our patients with HTN to have 2
  BPs within the last year.

10
Optional Key Diabetes Measures

• At least 70 of our patients will have a dilated
  eye exam within 1 year.
• At least 70 of our patients will have an LDL
  lt100 in the past 12 months.

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Registry

• The registry was populated by extracting data
  from our Medical Information System.
• Monthly report will be run for patient updates.
• POF charts are identified with a green sticker.
• Charts are pulled and results are taken from the
  chart abstraction tool and entered into PECs.
• Currently there are 100 patients in registry.

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Key Partnerships

• Bureau of Primary Health Care (BPHC)
• Centers for Disease Control and Prevention (CDC)
• Detroit Community Academic Urban Research Center
• Henry Ford Health Systems (HFHS)
• Michigan Department of Community Health (MDCH)
• Michigan Family Independence Agency (FIA)
• Michigan Primary Care Association (MPCA)
• National Association of Community Health Centers,
  Inc. (NACHC)
• Skillman Foundation
• University of Michigan (U of M)
• School of Nursing
• School of Public Health
• School of Social Work
• U.S. Department of Health and Human Services
  (DHHS)
• Wayne State University School of Social Work
  (WSU)
• Karmanos Breast Cervical Cancer Control
  Program (BCCCP)

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SELF MANAGEMENT

• Currently Testing
• Best way to distribute SM form to patients
• Dental Self-Management Goals
• Testing new glucometer discount strips for
  patients
• Implemented into our Delivery System
• Patient chosen SM form
• Group educational series held once a week
  sessions are available in English and Spanish

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Community

• Currently Testing
• Availability and location of exercise facilities
  in Southwest Detroit
• Partner with Cheryl Tannas, CDE, at Herman Kiefer
  Health Center to share resources patient
  education material
• Safety Net Access Project for uninsured patients
  who need specialty referrals
• Implemented into our Delivery System
• Built relationship with State DCP
• Partnered with REACH project to provide
  culturally appropriate health education series

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Healthcare Organization

• Currently Testing
• Board Member attend team meeting once every 2
  months
• Implement Care Model with our QI committee
• Implemented into our Delivery System
• Collaborative report submitted to BOD on monthly
  basis team presents quarterly to the board
• Collaborative report to staff at monthly meeting

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Decision Support

• Currently Testing
• Using DCA 2000 during same day visits to evaluate
  patients medication care plan
• Posters ordered for exam rooms
• Bi-monthly lectures for providers at provider
  meetings (various topics)
• Implemented into our Delivery System
• Use pocket guides to embed guidelines for
  medication treatment into daily practice
• Establish criteria for referral of patients to
  specialists and assure that PCPs have access to
  expert support from specialists for consultation

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Clinical Information System

• Currently Testing
• Easy access for providers to clinical info from
  the registry
• Tracking of PECS labs to assure accurate entry
  into PECS
• Implemented into Delivery System
• Appt system flags patients in our registry
• Develop guidelines for creation and use of
  registry including designating personnel for
  tasks and registry maintenance
• Use the registry to track, report and communicate
  results and outcomes of care effectiveness over
  time and across providers and populations
• Use registry to pull lists of patients needing
  reminders for follow-up care

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Delivery System Design

• Currently Testing
• Assure appt system supports the needs of our
  patients including follow-up activities and
  multiple appts on same day
• Implemented into Delivery System
• Use outreach workers to connect with patients
  outside office
• Transportation to clinic Henry Ford Hospital
  for peds, seniors and OB patients
• RX protocol implemented
• Nurse rotation schedule for patient discharge and
  nurse triage when center opens

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Functional and Clinical Outcomes

• Measures Goal as of 4/23/05
• 2 HbA1cs in last yr gt90 14.3
• Average HbA1c lt7.0 7.9
• Documented Self
• management goals gt70 ----
• BP lt130/80 gt40 43
• ACE inhibitor for pt over age 55 gt75 60
• Dental Exam in past year gt70 16.3
• REGISTRY SIZE 100 100

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Communication Plan

• At the center level
• Monthly staff meetings and BOD meeting
• Presented collaborative info at diabetes group
  meetings
• Story board in waiting room
• At the community level
• Discussed collaborative with REACH partner
• New partner Cheryl Tannas, CDE, at neighboring
  center

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A story to share.our staff

• One way the collaborative has impacted the staff
  is it has made the staff more cohesive. In the
  past, each dept in the center often worked
  independently. In selecting the team,
  individuals were chosen from administration,
  medical and dental. Thus each component of our
  team could work together to successfully drive
  change in our organization. We are now working
  as one entity to improve chronic illness care.

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A story to sharethe organization

• It has forced the organization to evaluate our
  day to day operations and generate innovative
  ideas on the way we manage chronic illnesses.

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A story to share.the patient

• One of the most remarkable changes we have
  observed is in the patients with diabetes making
  and keeping dental appointments. An example of
  this is Maria V., a 59 year old Hispanic woman.
  Maria V. had her initial physical exam at CHASS
  Center 01/04 and was told to schedule a dental
  appt which she did not do. Her second complete
  physical exam was 02/05 and once again she was
  told to schedule a dental appt and again did not
  make one. As part of the collaborative a PDSA
  was done to test the effectiveness of a diabetic
  reminder letter. The letter read as follows
• As a patient with diabetes there is much you
  can do to protect your health. Regular
  testing and exams can help find problems before
  they become serious.
• Our records show that you may be due for a
  DENTAL visit. Please call to schedule an
  appointment.
• Maria V. was one of the first patients to
  schedule a dental appt. as a result of the
  reminder letter. She was given an initial oral
  exam by Dr. Claiborne, the centers dentist, on
  04/05. The dental exam revealed severe
  periodontal disease, which is one of the oral
  complications of diabetes. Maria V. was given
  patient information (in Spanish) and follow-up
  appts for extractions and root scaling and root
  planning. Maria V. was very receptive to the
  info presented to her. It is our hope that now
  that she knows the severity of her periodontal
  disease she will continue with her dental
  treatment. Also, here at the center we are
  trying to schedule both medical and dental appts
  on the same day whenever possible. The next time
  Maria V. is in the center she will be seen in
  both the medical and dental departments, which is
  very convenient for Maria V. since she does not
  drive and has to arrange transportation.

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Anticipating Barriers and Issues

• Barriers Issues
• Staff shortage (all areas)
• Resistance to change
• Number of steps involved to change or implement
  new policies
• Time constraints
• Negativity
• Coordinating schedules for specialists to meet
  with providers

• Information Systems
• Linking current system with PECS
• Flags for needed tests according to Quality Care
  Guidelines
• Resources for Time and Equipment
• Need monitors/strips

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Senior LeadershipMaking the Case For Change

• The CEO and Medical Director (Physician Champion)
  shared the Health Disparities Collaborative
  Executive Summary, the Changing Practice,
  Changing Lives video and the Learning Session 1
  storyboard with the Board of Directors and the
  providers with monthly updates.
• The Physician Champion and IT Specialists
  presented the Health Disparities Collaborative
  Executive Summary and the Learning Session 1
  storyboard to administrative and support staff at
  the monthly meeting and on an ongoing basis at
  that meeting and individually.
• The response to making the case for change has
  been overall very positive because of the HDC
  goals to (1) generate and document improved
  health outcomes for underserved populations (2)
  transform clinical practice through new
  evidence-based models of care (3) develop
  infrastructure, expertise and multi-disciplinary
  leadership to improve health status and (4)
  build new and strengthen current strategic
  partnerships.