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
- Assigned a dedicated Community Resource Coordinator to facilitate communication with hospital partners and assist patients in navigating care;
- Trained staff in approaches to improved care coordination and population health management based on best practices;
- Revised notification and follow-up procedures with partner hospitals and area urgent care centers;
- Established and implemented protocols for sharing patient information across project partners; and
- Planned and hosted an invitational conference (April 19, 2016) on “Patient-Centered Transitions of Care” for local and regional health professionals, featuring a keynote address presented by internationally renowned expert, Eric A. Coleman, MD, MPH, Professor of Medicine and Head of the Division of Health Care Policy and Research at the University of Colorado Anschutz Medical Campus, and Director of the Care Transitions Intervention. Dr. Coleman’s remarks and additional sessions focused on enhancing the role of patients and family caregivers to improve the quality of their care transitions.
- 2015-2016 Key Project Outcomes
- Through transformation of the health center’s practices and with the support of external partners, ACCESS was able to successfully demonstrate improved outcomes. The proportion of diabetic patients with poor control was decreased for patients in both the Chronic Disease Collaborative and Health Home Initiative cohorts.
- New procedures and processes for communication and access to patient information resulted in improved rates of post-hospital discharge follow up. For the Health Home Initiative cohort, the benchmark of 80% receiving care coordination services within 72 hours was exceeded, and improvements were also achieved for the center’s other patients.
- The Transitions of Care conference led to the establishment, under the Health Center’s leadership, of a regional Transitions of Care Network improving patient follow-up and coordinating the provision of essential services.
- 2016-2017 Key Grant Activities
- Expanded the project from its original location to the center’s six sites, with a focus on reducing the percentage of all patients with poor diabetic control to meet the Healthy People 2020 target of 16%;
- Incorporated behavioral health specialists and pharmacists in the care management team;
- Established eye service and initiated on-site diabetic eye disease screening;
- Integrated oral health services across all sites;
- Piloted a new documentation management process and enhanced staffing to facilitate improved data collection and analysis;
- Extended and supported the regional collaborative Transitions of Care Network;
- Disseminated best practices and lessons learned through presentations at the Association of Clinicians for the Underserved (ACU); and Missouri Primary Care Association Annual Quality Conference; and
- Planned and hosted the second regional Patient-Centered Transitions of Care conference (May 3, 2017) featuring colleagues from St. Louis Integrated Health Network. Conference participants were introduced to health equity, collective impact and health ecosystems concepts, and engaged in facilitated exercises to identify, inventory and map the infrastructure supporting a comprehensive, patient-focused health ecosytem for the area’s residents.
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.
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.
Website at http://www.accessfamilycare.org/