A Unique Coalition is Reducing Disparities in Care in Rochester, New York

This improvement story originally appeared in IHI's 2006 Progress Report.
A public and private coalition in northeast Rochester, New York, where the median household income is less than $22,000, is working to reduce disparities in care. Reweaving the Safety Net, an ambitious project begun in 2003, is aimed at linking poorer residents with needed health care and social support services.
Included in this broad initiative is the Clinical Transformation Project, launched initially in five local practices and now spread to ten. Developed by IHI and the Institute of Medicine, and directed by IHI faculty member L. Gordon Moore, MD, a local family physician, the project seeks to significantly increase the efficiency and efficacy of care. “We believe better systems produce much better outcomes for patients,” Moore says.
The practices are working toward three goals:
  • To create and support high-functioning clinical teams where workflow is efficient and staff members are properly trained
  • To implement open access scheduling so patients can make same-day appointments
  • To implement systems and tools that support consistent delivery of routine and disease-specific preventive care
The work is paying off. “So far the project has touched about 23,000 lives. Our best-performing teams are showing a 14 to 24 percent decline in emergency room visits for their Medicaid patients. As more teams succeed, we expect to see a significant decline in hospital admission for conditions like diabetes and asthma,” says Moore.
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