Project Name: Comprehensive Diabetes PCMH Integration

Project Overview: The Comprehensive Diabetes PCMH Integration project was directed toward attaining service utilization and outcome improvements for the community’s diabetic patients, regardless of insurance status, focusing on those who do not meet the Chronic Disease Collaborative target goals. The project built on the center’s participation in the CMS Advanced Primary Care Practice Demonstration program and Missouri HealthNet Primary Care Health Home Initiative.

Comprehensive Diabetes PCMH Integration Project Goals were to improve outcomes for patients with diabetes and other chronic conditions.

Objectives were to:

  • Help patients more effectively navigate ongoing care needs and care transitions;
  • Expand the health center’s capacity to operate as a high-performing Patient Centered Medical Home, especially for at-risk, chronically ill patients;
  • Expand referral options for specialty services;
  • Reduce ER visits and hospital admissions; and
  • Improve target health outcomes for those most at risk.
  • 2015-2016 Key Grant Activities
  • 2015-2016 Key Project Outcomes
  • 2016-2017 Key Grant Activities
  • 2016-2017 Key Project Outcomes

    • Overall, the percentage of diabetics with poor control (HbA1c>9 or untested) declined from a baseline 38% at the start of the program, to 28%. Patients in the Health Home Initiative had the greatest and most sustained improvement, from a baseline of 29% (2015) to 18% (2017).
    • The percentage of diabetic patients receiving annual eye exams increased from 47% to 76%, following the implementation of a system-wide on-site screening program utilizing retinal fundus cameras. In addition, enhanced screening facilitated more timely referrals for patients needing follow-up.
    • The documentation management pilot increased the number of reports from outside sources scanned and imported into ACCESS’ E.H.R. system from 238 documents in Quarter 1 to 9,845 in Quarter 4.

Project partners:

The Community Clinic of Joplin, Freeman Health System, Mercy Hospital, Area Community Health Emissaries, Missouri Primary Care Association, and Coleman Vision Improvement Center.

About the Grantee:

ACCESS Family Care (ACCESS) was founded in 1996 as a Federally Qualified Health Center (FQHC) for the purpose of increasing access to primary health care for those who lack medical insurance coverage. ACCESS provides quality medical, dental, and pediatric care on a sliding-scale fee at clinics in Anderson, Cassville, Joplin, Neosho, Mount Vernon, and Lamar, Missouri.

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