Diabetes:

Aim Example 1:

The organization will redesign its system to provide improved care for our patients with diabetes.  We will accomplish this through implementation of the Chronic Care Model.  This will be evidenced by:

• At least 90 percent of our patients receiving two HbA1cs, three months apart, within one year
• An average HbA1c less than 7.0
• At least 70 percent of our patients with documented self-management goals
• At least 75 percent of our patients 55 years and older with current prescriptions for ACE Inhibitors or ARB medication
• At least 70 percent of our patients with blood pressure less than 130/80

Population of Focus:  The population of focus will be all the patients in Dr. Jones' practice (approximately 100). New patients identified with diabetes will be added as they come into the practice and/or are initially diagnosed.

Guidance:  The organization will develop and maintain a registry of all 100 of our patients with diabetes.  We will focus initially on patient self-management methods and delivery system design. Once the changes have been implemented, the other physicians and physician assistants and their panels will be included.

Aim Example 2:
Our organization will delay and decrease complications from diabetes, redesign self-management, decision support, and delivery system, and become a center of excellence in our community.

Goals:

• 90 percent of patients with two HbA1c's, three months apart, in 12 months
• 70 percent of patients with a self-management goal
• 95 percent with lipid profile annually
• 70 percent with LDL < 130
• 95 percent assessed for smoking
• 100 percent of smokers counseled to stop

Asthma:

Aim Example 1:

Implement components of the Chronic Care Model to show a 40 percent increase in symptom-free days, 50 percent decrease in ER visits. 90 percent of patients with persistent asthma will be treated with antiinflammatory meds, and at least 90 percent of patients will have a written asthma action plan.

Aim Example 2:

An organizational approach to caring for the population of patients with asthma will be implemented using the Chronic Care Model so that there is 90 percent of patients with persistent asthma being treated with maintenance anti-inflammatory medications. At least 90 percent of clients with asthma will have an asthma flow sheet and action plan in their chart. 50 percent of clients with asthma will have an asthma trigger avoidance plan.

Depression:

Aim Example 1:
We will redesign the care system for patients with depression.  Using the Chronic Care Model as a guide, we will integrate depression screening and follow-up into our primary care processes.  By doing this we hope to achieve the following results: 80 percent of our patients who are newly diagnosed with depression will have a follow-up assessment within six weeks; the percentage of patients with a diagnosis of depression with a PHQ score less than five will increase to 65 percent.

Aim Example 2:

The organization will redesign the system of care to provide improved care to our patients with depression. We will accomplish this by making changes in the following areas: