Carolyn Shepherd
Vice President for Clinical Affairs
Clinica Campesina
"The clinic started about 27 years ago, in the kitchen of a woman, with one nurse practitioner." (0:48)
I’m Carolyn Shepherd. I’m a physician, a family practice physician. I’m the Vice President for Clinical Affairs at Clinica Campesina. Clinica is a community health center, a federally-qualified community health center in Colorado. We take care of about 25,000 patients and provide about 108,000 visits a year, to primarily low-income but also other patients who have barriers to health care, such as language barriers. The clinic started about 27 years ago, in the kitchen of a woman, with one nurse practitioner. And that nurse practitioner actually still works at Clinica. And we have grown from about seven staff when I joined in 1988. Now we have 170 staff.
"The 'ah-ha' moment for all of us was when we went back with our first set of data, which showed that we were all doing horribly." (1:24)
In 1999, we were in the first pilot group to do the IHI Breakthrough Series on diabetes with Ed Wagner. When the feds came and asked us to participate in this pilot project, we said, “No, we’re not interested.” They were looking for someone from our region. And they asked us. And we felt like we were very busy right then and we didn’t have the energy in the organization to do it. They went around and asked a bunch of other people who, fortunately, also said no, and they came back around to us. And, and we then said, “OK, we’ll do this.” And not because we had this massive moment of vision or foresight, but only by default really.
We take care of primarily a Hispanic population. Our number one chronic disease is diabetes. And the pilot was in diabetes, which is one of the reasons we decided, at the end, to go ahead and participate. And we sent a team to work with four other community health centers and then a lot of health care organizations, there were teams from Mayo, Cleveland Clinic, everywhere. We were adequately intimidated. And the “ah-ha” moment for all of us was when we went back with our first set of data, which showed that we were all doing horribly when you included every patient with a diagnosis of diabetes. And it just became clear that we need to do population planned care and not one-on-one patient care.
"We tried to change our approach from non-compliant to not-yet-engaged." (1:16)
We started with diabetes, building a registry, setting outcomes measures, producing data, sharing it with staff, putting it on data walls. And after two years, we realized that it really wasn’t the patient who was not compliant, it was our systems that were just absolutely inaccessible. And so we migrated from our diabetes focus to an office redesign focus. And we looked at three major areas: access to care, office efficiency (we just had systems that had been in place for 25 years for really no good reason, but we kept doing things that way), and then trying to do something about alternative visits (trying to figure out if patients were not coming for care because we had not yet found something, a model that worked for them). And we tried to change our approach from “non-compliant” to “not-yet-engaged.” And that left us as the responsible engagers, not the patient. So we focused really on those three main areas in our system redesign, using Ed Wagner’s planned care model of decision support, system design, information systems in patient self-management.
"We have made continuity king." (1:28)
We have rebuilt, really from the ground up, all our three clinic sites. So we have an architectural structure that supports teamwork. We’ve divided into what we call pods, which are microsystems that are basically focused around patient care. And all the care the patient needs can be found on those pods. We have made continuity king. We try our very best to drive up continuity in every change we do. And we measure continuity around every change we do to be sure we’re not causing a problem in the system for that. And then, we’ve had a lot of luck in changing from a one-on-one, physician or nurse practitioner, PA visit to group visits, which works particularly well in our patient culture. That sense of community and continuity, ongoing group visits, has been very effective in motivating patients’ compliance with needed self-care. And that model is really working well for us, so that we have group visits now for our diabetes patients, our prenatal patients, our depression patients. We did a group visit for our chronic pain patients. We have group visits for ADHD. So we’re really trying to find difficult management problems that we’re having at clinic and improving our outcomes by bringing patients together in a community to work on their patient self-management together.
"It’s hard for people to realize that there’s going to be change every single day." (1:00)
Everybody would like the feeling that there’s a target and you could get there. And I think it’s difficult to say to people, “Fantastic, we’re doing this now. Let’s go there.” So the fact that there isn’t any endpoint, that any change brings around the opportunity to solve the next problem. And it would just be so nice to throw a big ice cream party and say, “We’re there.” And that’s never going to happen. That’s just not what this process is about. And people are, can become a little weary; there isn’t an artificial goal in there, where they could say, “Oh, got it done.”
I think we try to celebrate a lot. And any time we make any little win, we go out and buy everybody, you know, Starbuck’s cards. And we try to make, you know, some sort of celebration every, every place we have an opportunity. At the same time, change is hard. And it’s hard for people to realize that there’s going to be change every single day.
"The 100,000 Lives Campaign has really helped people understand that safety is a key component of health care." (0:53)
The 100,000 Lives Campaign has really helped people understand that safety is a key component of health care, and that we have to have a plan around that. And even in the ambulatory care setting, where we don’t do central lines and have in-dwelling catheters, nonetheless, just the concepts of bundling care packages together and saying, “We want patients to get all of every one of these every time,” has been important. And I think that our improvement process has allowed all of our staff — we have 25 physicians and nurse practitioners and PAs —and they’re involved in hospital committees. And they can talk about outcomes. They can talk about PDSA cycles. They can talk about rapid change. Just from our ambulatory care setting, so we bring something to the hospital setting.
Related Information:
Clinica Campesina Case Study
Removing Barriers to Care: Clinica Campesina
07/18/2006
