To increase achievement of evidence-based diabetes treatment targets across participating practice teams by 20 percent or more over a 12-month period using the collaborative learning model, and to develop local expertise and shared goals among teams to improve diabetes management and control across the MaineHealth region.

• HbA1c:
  •  Testing:  Percent of patients with diabetes with one or more HbA1c tests in the previous 12 months
  • Glycemic control:
    • Percent of patients with diabetes with HbA1C less than 7.0 percent
    • Percent of patients with diabetes with HbA1C less than 8 percent
    • Percent of patients with diabetes with HbA1C greater than 9.5 percent
• LDL:
  • Testing:  Percent of patients with diabetes with one or more LDL tests in the previous 12 months
  • LDL control: Percent of patients with diabetes with LDL less than 100
• Blood pressure:
  • Testing:  Percent of patients with diabetes with one or more assessments of BP in the previous 12 months
  • BP Control: Percent of patients with diabetes with BP less than 130/80
• Self-management: Percent of patients with diabetes with at least 1 documented self-management goal in past 12 months (specific self-management goal to be set by team)

MaineHealth convened local physicians, diabetes educators, and other clinicians to develop the TARGET Diabetes program, a comprehensive program built on the framework of the Chronic Care Model.  It then implemented this program across the local region by using the learning collaborative model to work with interested practices. 

• MaineHealth developed patient and provider “TARGET Diabetes” tools as a means of incorporating nationally accepted (ADA) guidelines into care and building local provider acceptance of tools.
• Used these tools as foundation for raising interest in diabetes improvement with local physician practices.
• Worked with health system leadership and local physician organizations to encourage interested practices to join yearlong diabetes learning collaborative.
• Provided health system staff and administrative structure to support 12 practices from across local region to implement changes in their practice to improve diabetes care and outcomes, including 3 Learning Sessions, site visits to practices, monthly conference calls, and electronic listserv
• Modified publicly available diabetes registry (ORDEMS) to create a local tool (MHDEMS) available to all collaborative practices, and provided hands-on training to practice staff on use of the registry.
• Established standard set of “core measures” that each practice was asked to track during their participation in the collaborative using this diabetes registry (or practice electronic medical record).
• Collated data monthly across 12 practice sites, and shared aggregated data with teams and health system senior leadership.
• Convened senior leaders from participating practice midway through collaborative for facilitated discussion of practice needs, and effective roles of senior leaders.
• Integrated collaborative improvement effort with other related improvement efforts in state, particularly with an emerging employer-based pay-for-performance initiative.
• Looked for and used all available means to publicly communicate practices’ participation in this improvement effort, highlighting their role as leaders in their community.
• Encouraged linkages to other diabetes improvement resources and programs in the state (e.g. state Diabetes Prevention and Control Program, local diabetes self-management training programs).

A coordinated program to improve population outcomes sponsored by a small health system, led by local clinicians, and based on collaborative learning provided an effective means of achieving improved diabetes care and outcomes in physician practices across a geographically and structurally diverse healthcare system.  Lessons learned include:

• Involve and gain support from organizational and practice senior leadership as early as possible.
• Understand the organizational, structural, and cultural differences across practices, and adapt support for different practices based on their needs and capacity.
• Be sensitive to the varying levels of practices’ understanding and experience about quality improvement activities, and adapt QI language, tools, and methods so that it is more easily understood by busy practitioners.
• Whenever possible, build on locally-developed tools in order to strengthen local buy-in and acceptance by local providers.
• Recognize that not all practices know how to work effectively as teams; incorporate team-building exercises and strategies into learning collaborative model.
• Whenever possible, encourage the use of a standard diabetes registry to track outcomes and drive improvement efforts across practices; having to support different registries creates unnecessary distraction and duplication of effort.
• Actively seek out and use all opportunities to integrate improvement activities into other related improvement initiatives in the region and state (e.g., payer pay-for-performance initiatives; state health department resources).
• Assist practices in identifying local community resources and relationships, as many do not have established means for making these connections.

Lisa M. Letourneau MD, MPH
Director Clinical Integration
MaineHealth
letoul@mmc.org

[Storyboard presentation at IHI's National Forum, December 2004]