East Chicago Community Health Center

1
East Chicago Community Health Center

• Midwest Cluster

2
East Chicago Community Health Center TeamSugar
Snatchers

• 100 W. Chicago Avenue East Chicago, IN
• 46312
• 2 Internal Medicine Physicians, 2 Pediatric
• Physicians, 3 Nurse Practitioners, 2
• Midwives, 2 OB GYN,
• Internal Medicine, Pediatrics, Obstetrics,
• Adult HIV, Family Planning, Social Services
• Total Number of patients served 6,748
• Number of patients diagnosed with diabetes 671
• Not certain Homeless8, Migrant1 Seasonal4
• Ethnic mix Asian/Pacific Islander 15 patients
• Black/African American
  1,820 patients
• American Indian/Alaska
  native 5 patients
• White 669 patients
• Hispanic/Latino 3,987
  patients
• Unreported/Refused to
  Report 251 patients
• Total 6,748 patients

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Team Members

• Cornell Brantley CEO/ED (Senior Leader)
• Luis Manyari, MD (Physician/ProviderChampion)
• Nora Arroyo RN Coordinator for Quality
  Initiatives (Team Leader)
• Heine Ruiz, MD Medical Director
• Juan Campos MIS Contact (Computer Systems
  Analyst)
• Irene Verduzco Social Services
• Paul Varney, Nurse Practitioner
• Jennifer Rowan LPN (Clinical/Technical Expert)
• Theresa Thomason Medical Records

4
AIM

• East Chicago Community Health Center will
  redesign its system to provide improved care for
  our patients with diabetes. We will accomplish
  this through implementation of the Care Model.
  This will be evidenced by
• An average HgbA1c less than 7.0
• At least 90 of our patients receiving at least 2
  HgbA1cs 3 months apart within one year
• At least 70 of our patients will have documented
  self-management goals
• At least 75 of our patients 55 years and older
  will have current prescriptions to ACE inhibitors
  or ARB medication.
• At least 40 of our patients will have BP lt
  130/80.
• At least 70 of our patients will have LDL lt 100.

5
Population of Focus

• Population of Focus StatementEast Chicago
  Community Health Center will target 100 patients
  of Dr. Manyari. These patients will be the main
  focus to begin our registry at this time.
• We chose Dr. Manyaris patients for the
• collaborative because the other internist is
• also the medical director and we felt that he
• would have more time to devote to the initiative.

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Key Diabetes Measures

• Measure
  Goal
• Average HgbA1c
  lt7.0
• Patients with 2 HgbA1cs in last
• Year (at least 3 months apart)
  gt90
• Documentation of self-management
• goal setting
  gt70
• Cardiac Risk Reduction
• 1. Option 1 Statins
  gt60
• 2. Option 2 ACE inhibitors or ARB
• medication
  gt75
• 3. Option 3 Aspirin or other anti-
• thrombotic agent use.
  gt80
• Patients with BP lt 130/80
  gt40
• Patients with LDLlt100
  gt70
• If have integrated dental clinic
• Dental Exam in past year
  gt70

7
Registry

• Patients were chosen on the basis that they must
  have been seen within the past 6 months or they
  were excluded from the initial registry.
• Chart abstraction Tool filled out and then
  information entered into PECS was the data entry
  process.
• Current number of patients in registry 95.

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Key Partnerships

• St. Catherine Hospital is the main
• community health partner we have at this
• time. Partnerships with the hospital are
• being considered, but have not yet been
• implemented.