Health Disparities Collaboratives: Improving Diabetes Care in 3,400 Health Center Sites

With diabetes currently the seventh leading cause of death in the United States and its prevalence rising dramatically along with rates of obesity, innovative programs to address this disease and its consequences are increasingly critical. In 1998 the Bureau of Primary Health Care (BPHC), a division of the US Department of Health and Human Services, teamed up with the Institute for Healthcare Improvement (IHI) to form the Health Disparities Collaboratives. The BPHC oversees programs that offer care to people who are underserved by the United States health care system — the underinsured and the uninsured. Twelve million people, a diverse and often high-risk population, are supported through more than 3,400 health centers.
 
BPHC had set an ambitious goal, which provided the impetus for the Collaboratives. It involved nothing less than a transformation of health care by 2010, by eliminating disparities in health care and guaranteeing underserved Americans 100 percent access to care. Diabetes was the first focus, as it disproportionately affects minorities. Eighty-eight health centers formed the first diabetes Collaborative, joined by 115 others in a second phase. BPHC eventually wants every one of its health centers to be part of a Collaborative. 

 

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Structure of the Solution
The Collaboratives, which have been adapted from IHI’s Breakthrough Series, have three main components: a learning model, a chronic care model, and an improvement model. The learning model is the education portion of the initiative and consists of two parts: learning sessions and action periods. Learning sessions are three two-day sessions that train interdisciplinary teams from each health center to become a community of active learners. In the action periods, which take place between learning sessions, teams share information, through the collection and submission of data and progress reports, and participation in conference calls and listserv discussions.
 
A six-part Chronic Care Model is the second major element of the Collaboratives: patient self-management, decision support, clinical information system, delivery system design, organization of health care, and community.
 
In the self-management element of the model, patients learn how to form partnerships with their doctor to improve their care and advance their own treatment, especially by making diabetes management a part of their daily lives. Educational materials, action plans, and goals that are reviewed as a regular part of follow-up form the core steps in this element. Patient visits are planned in advance, with the goal of having patients see all needed types of providers (ophthalmologist, podiatrist, nutritionist) at the same visit. And group visits allow patients to interact with other patients in similar situations.
 
The decision support element provides clinicians with evidence-based guidelines and protocols, links primary care providers with specialists they can call on for expert advice, and provides training for all members of the care team.
 
The clinical information system creates a registry through which health centers can track the population involved in the Collaboratives, enabling them to look at their clinic population as a group. Data on patients with diabetes can be entered and manipulated to generate reminders and care planning tools for patients, as well as to provide team members with feedback about their progress.
 
The delivery system design element focuses on the delivery of patient care. This requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient’s status; and making follow-up a part of standard procedure.
 
The organization of health care moves chronic care to the forefront of a center’s business plan, ensuring that senior leaders are integrally and visibly involved with the Collaboratives. It reinforces the need for centers to commit themselves to a culture of health education and preventive services.
 
Finally, the local community is recruited as a partner to support the Collaboratives, through the provision of space, resources, and education.
 
The third and final element of the Collaboratives is the Model for Improvement, in which teams focus on how to test and implement positive changes quickly. This model asks three basic questions and uses a quick-change cycle known as PDSA (Plan-Do-Study-Act). The questions are: What are we trying to accomplish? How will we know that a change is an improvement? And what changes can we make that will result in improvement? Teams define their specific aims, define the measures they will take to accelerate improvement, and test the changes they make. The end of one PDSA cycle leads directly into the next, creating chains of linked cycles that provide continuous improvement.
 
What Difference Does It Make?
As with any initiative, the proof is in the proverbial pudding. Thus far, the diabetes Collaborative has been able to show impressive results. One desired outcome was to increase the number of patients who had two HbA1c tests per year; early data showed that the overall percentage of patients meeting this goal was 300% greater than before the collaborative began. Individual clinics have also made enormous strides.
  • Grace Hill Neighborhood Health Centers (St. Louis, Missouri, USA) have achieved an average decrease in HbA1c levels from 10.76 to 8.23. 
  • La Clinica Campesina Family Health Services (Lafayette, Colorado, USA), whose population is 40 percent Hispanic, has also seen dramatic changes in their patients with diabetes. Without adding any extra resources, but simply shifting their focus to the Collaborative elements, the center also reduced average HbA1c levels from 10.5 to 8.5. Cory Sevin, the center’s vice president, notes that even a 1% reduction "means a 15 percent to 18 percent reduction in mortality, heart attack, and stroke, and a 35 percent reduction in cardiovascular complications."
 
With success stories like these to show for the effort, it’s little wonder the Health Disparities Collaboratives are expanding to include other chronic diseases, including HIV, asthma, and depression.​
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