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A Model for Quality Care
Collaboratives use systems approaches to improve quality of care and utilize evidence-based strategies including the Chronic Care Model, learning sessions, and a rapid improvement process. The Care Model (see Figure) envisions communities having supportive resources and policies, which are linked to health systems organized to provide good chronic illness care. These health system components include:
- Self-management support (i.e., patients acquire the skills necessary to be active participants in managing their own care);
- Delivery system design (i.e., staffing, appointments, etc. are organized to support quality care);
- Decision support (i.e., evidence-based guidelines are integrated into practice); and
Chronic Care Model
- Clinical information systems (i.e., patient care is proactively managed using computerized systems that include a patient database, a reminder system for implementing guidelines, and provider feedback on compliance with guidelines).
The Chronic Care Model is a population-based model that relies on knowing that patients have the disease, assuring that they receive evidence-based care, and actively aiding them in participating in their own care. The implementation of this comprehensive system leads to informed, activated patients, and prepared, proactive practice teams, and produces improved outcomes. Specific quality measures are tracked using the clinical information systems mentioned above.
State Heart Disease and Stroke Prevention programs generally work with two major types of collaboratives:
Health Disparities Collaborative
The Health Resources and Services Administration’s Bureau of Primary Health Care (BPHC), in partnership with the Institute for Healthcare Improvement (IHI), the Centers for Disease Control and Prevention (CDC) and other professional networks, supports the implementation of Health Disparities Collaborative in federally-funded health centers throughout the country. The Health Disparities Collaborative initially addressed diabetes, asthma, and depression. In 2001 these collaboratives were expanded to address cardiovascular disease.
The mission of the Health Disparities Collaborative is to achieve excellence in practice through the following goals: 1) to generate and document improved health outcomes for underserved populations; 2) to transform clinical practice through models of care, improvement, and learning; 3) to develop infrastructure, expertise, and multi-disciplinary leadership to support and drive improved health status; and 4) to build strategic partnerships. This mission is highly complementary to the Heart Disease and Stroke Prevention Section aims of promoting the primary and secondary prevention of heart disease and stroke and eliminating health disparities.
State primary care associations are key partners in supporting the Health Disparities Collaborative. These associations represent several types of health centers including those, which are federally funded. The health centers serve as primary care safety net providers, dedicated to assuring access to comprehensive primary care for underserved populations and eliminating health disparities. Primary care associations form a core part of the Health Disparities Collaborative infrastructure, with staff serving as Cluster (i.e., multi-state region) directors and coordinators for the collaborative.
Each health center that participates in the Health Disparities Collaborative forms a team, usually consisting of 3-5 staff (with a provider champion, other practitioners, and office staff), that attends a series of national learning sessions over 13 months. The sessions are designed to teach center teams how to implement the concepts of the Care Model, conduct rapid quality improvement, and utilize a clinical information system.
The clinical information software called the Patient Electronic Care System (PECS) performs the following major functions:
- Gives providers a comprehensive picture of a patient’s health status and documents medications, lab results, and screening tests;
- Makes the latest evidence-based guidelines conveniently available and prompts the provider to implement the standard of care for all patients;
- Generates lists of patients who are in need of care such as a follow-up visit, lab test, or referral;
- Generates summary statistics on cardiovascular patients in the health center. This includes the ability to assess health disparities according to gender, race/ethnicity, and insurance coverage.
State departments of health have partnered with quality improvement organizations (QIOs), primary care associations, and others to develop collaboratives, which either help spread the BPHC’s efforts (i.e., among smaller clinics affiliated with larger health centers that have participated in national training) or reach a broader population such as privately-funded health centers and clinics. These collaboratives use essentially the same methods as those used in the national effort. Learning sessions are conducted within states, and clinical information tools similar to PECS are used.
Public Health Role
State cardiovascular health programs make significant public health contributions to both BPHC- and state-supported collaboratives. The major opportunity for such programs in these efforts is to assist with building capacity and spreading utilization of collaboratives. Specific strategies include:
- Clinical Information System Support: providing technical assistance and/or financial support to establish cardiovascular patient management systems (i.e., one-time assistance for computer software, initial data entry).
- Training: providing technical assistance and/or financial support for learning sessions on the Care Model, the quality improvement process, and related strategies.
- Community Linkage: providing technical assistance on community resources and policies.
- Sustainability and Spread: providing technical assistance and/or financial support to maintain and expand center staff understanding of the collaborative process. As health centers experience staff turnover, it is important that new staffs are trained in collaborative processes. This is also needed as centers, which were trained in other topics, expand their focus to include cardiovascular issues. Finally, larger health centers, which participate in the national learning sessions often, are affiliated with smaller satellite health centers; these satellite centers need the opportunity to be trained in collaborative methods.
The Arkansas Heart Disease and Stroke Prevention Section has participated in a number of activities designed to support the BPHC- and Arkansas Chronic Illness Collaborative. For example:
- The program partnered with the state’s CDC-funded Diabetes Prevention and Control Section, as well as the Community Health Centers, Inc. and Arkansas Foundation for Medical Care, to form the Arkansas Chronic Illness Collaborative for people with diabetes and cardiovascular disease.
- The program partnered with Community Health Centers of Arkansas, Inc. and Area Health Education Centers to develop patient management databases among select health centers. One-time funds were used to conduct chart reviews and support initial patient data entry in order to develop these patient management databases. Once established, the health centers maintained the system. The establishment of the databases helped qualify the centers to participate in either a BPHC Health Disparities or the Arkansas Chronic Illness Collaborative.
- The program supports training of new staff in health centers, which have already been through the Health Disparities Collaborative training and of satellite centers affiliated with previously trained primary center sites.
Benefits of the Collaborative for State Cardiovascular Health Improvement Efforts
The Collaborative benefits state cardiovascular health improvement efforts in a number of ways. First, data may be shared on how systems changes have improved quality of care (i.e., increases in hypertensive patients with blood pressure control). Second, health centers become champions for community resources, policies, and environmental changes, which reinforce patients’ ability to manage their own care. Additionally, and particularly for those collaboratives implemented among community health centers and health education centers, they constitute a specific strategy for addressing health disparities among vulnerable populations.