Information & Quality Healthcare Helps Improve Diabetes Care Through Electronic Tracking was on the American Diabetes Association (ADA) standards of care. …
Pursuing Perfection: Raising the Bar for Health Care Performance
Phase II Executive Summary
Submitted January 2002- Funded April 1, 2002
Community-Wide Healthcare Transformation:
Innovating Infrastructure and Economic Policy
St Joseph Hospital
PeaceHealth
Bellingham, Washington
On behalf of:
Whatcom Community Health Improvement Consortium
Whatcom County
Community-wide Healthcare Transformation:
Innovating Infrastructure and Economic Policy
EXECUTIVE SUMMARY
St Joseph Hospital in Bellingham, Washington will serve as the applicant
for this Phase II Pursuing Perfection in Healthcare proposal on behalf of
the Community Health Improvement Consortium CHIC in Whatcom County,
Washington This proposal includes the following features:
1 An innovative approach to implementing a chronic disease model and
community infrastructure throughout a large
semi-rural service area by
coordinating the efforts and resources of specific primary care office
sites and groups, St Joseph Hospital, and various community agencies
2 Initial pilots focused on diabetes and CHF, given the prevalence of
these chronic diseases in our community, with a spread strategy to
include broader infrastructure support, primary care clinic readiness to
participate in organizational transformation, and additional priority
diseases Initial pilots also to include medication process improvement
re: hand-offs
3 A segmentation strategy that focuses on chronic disease level and
measures of patient readiness for self-management
4 Care coordination through cross-continuum chronic disease protocols that
are evidence-based, incorporated into a shared care-plan located on a
secured Website accessible to all team members, including patients
5 Care provided by cross-continuum care teams that include patients and
care managers linked to primary care clinics and serving as counselors,
educators, and navigators of service
6 Healthcare information to support 24/7 clinical decision-making and
patient self-management via continuation of our
electronic medical record
strategy and accelerated development of automated tools to support
disease management and associated workflows
7 Clinical outcomes measured according to promises made to Whatcom County
Because this proposal is community-based with several independent
organizations participating, it will require an innovative infrastructure
to support program development, project management, decision-making, and
human resources Our Phase I grant has been used to carefully plan an
approach for community-wide healthcare transformation via the building of a
chronic care model infrastructure, initial piloting of the infrastructure
with specific populations through segmentation, and solidifying this
infrastructure to ultimately support spread for citizens experiencing all
key disease states within Whatcom County Additionally, systems-modeling,
system simulation and dialogue with local payors are being used to
determine immediate, mid, and long-term clinical and financial impacts of
developing viable business model options and payment alternatives We
believe we are uniquely positioned to pursue healthcare perfection via our
community-wide effort and look forward to
continued support from the RWJF
Additionally, we believe the learnings from this project will be
uniquely valuable to similar communities nation-wide challenged to support
healthcare perfection through community-wide collaboration
Our Vision: Story of the Future - Clara is a 63 year old woman with
diabetes who has kept her serum glucose levels under good control She has
achieved this control through ongoing contact with her Care Manager, Nancy,
and quarterly visits with her PCP Clara, like all patients, began the
program by meeting with her care manager This visit included creating a
shared care plan, evaluating her self-management skills and providing her
information on community resources and the secured website, where she can
access her care plan, lab results, yearly diabetes wellness exam results,
as well as health information including the latest evidence-based
guidelines Clara set self-management goals after discussing
recommendations for controlling her diabetes and maintaining her health
She demonstrated use of her glucose monitor and completed a short computer
assessment of her knowledge of diabetes and preferred method of learning
Nancy made sure Clara had no
barriers obtaining test strips As part of her
care plan, warning signs were identified and ongoing contact with Nancy was
arranged Access to both email and a pager number 24/7 gave Clara peace of
mind Clara enters her daily blood sugars into a form on her secured
website where it becomes a run chart that is sent to her physician When
she sees a member of her care team, her care plan is updated
For the first eighteen months, Clara did extremely well When Nancy
called on the first Thursday of every month, Clara had always met her goals
and had maintained excellent control of her diabetes In July, Clara cut
her hand severely and goes to the ER During her intake, an alert that
Clara is on the diabetes registry pops up and a link to her virtual care
plan is made available to the ER staff which indicates a Care Manager has
been working with Clara It also provides a list of her current
medications She is asked how she would like her family involved in this
visit and what would make her more comfortable during her stay After the
examination and treatment, the ER Physician inputs a medication order to
prevent infection An alert pops up indicating a conflict between a
drug
ordered today and a current medication A change is made prior to the
order being relayed to the pharmacy for filling
Her Care Manager and PCP are sent an automatic email regarding her ER visit
and will be available as an alert on the EMR when they arrive at work
Nancy receives the email and contacts Clara by phone to check in and alert
her to the likelihood that her blood sugars will be elevated during her
recuperation They agree Clara will call if she needs anything and they
maintain the monthly call schedule Her care plan is updated and an alert
is sent to her entire care team Once Clara has healed, Nancy mentions the
opportunity to be trained as a lay instructor for the Living with Chronic
Illness community class Because Clara feels confident managing her
diabetes, she contacts the Parish Nurse and becomes a lay instructor for
Living with Chronic Illness
Source:peacehealth.org
