Health Disparities Collaboratives – Changing Practice, Changing Lives

Vision - Reduce disparities in health outcomes for poor, minority, and other underserved people

Dedication - Of health center staff, clinicians, patients themselves, and their communities.

Tools – A tested model that changes how we provide health care.

Partners

·        Community Health Centers, Migrant Health Programs, Healthcare for the Homeless programs in Iowa, Nebraska, and nationally

·        Bureau of Primary Health Care

·        Institute for Health Care Improvement

·        National Association of Community Health Centers, Inc.

The Chronic Care Model is a population-based model that relies on knowing which patients have the illness, assuring that they receive evidence-based care, and actively aiding them to participate in their own care.  It is recommended that a sub-group of the entire population be the focus of change in practice for the duration of the Collaborative.  The Model as shown above has six components:

Health Care Organization

·        Goals to improve chronic care are part of the organization’s business plan

·        Senior leaders visibly support improvement in chronic illness care

·        Benefit packages designed by the health care organization promote good chronic illness care

·        Provider incentives encourage better chronic illness care

·        Improvement strategies that are known to be effective are used to achieve comprehensive system change

Community Resources and Policies

·        Effective programs are identified and patients are encouraged to participate

·        Partnerships with community organizations are formed to develop evidence-based programs and health policies that support chronic care

·        Health care organizations coordinate chronic illness guidelines, measures and care resources throughout the community

Self-management Support

·        Providers emphasize the patient’s active and central role in managing their illness

·        Standardized patient assessments include self-management knowledge, skills, confidence, supports, and barriers

·        Effective behavior change interventions and ongoing support with peers or professionals are provided

·        The care team assures care planning and assistance with problem solving

Decision Support

·        Evidence-based guidelines are embedded into daily clinical practice

·        Specialist expertise is integrated into primary care

·        Provider education modalities proven to change practice behavior are utilized

·        Patients are informed of guidelines pertinent to their care

Delivery System Design

·        Team roles are defined and tasks delegated

·        Planned visits are used to provide care

·        The primary care team assures continuity

·        Regular follow-up is assured

Clinical Information Systems

·        There is a registry with clinically useful and timely information

·        Care reminders and feedback for providers and patients are built into the information system

·        Relevant patient subgroups can be identified for proactive care

·        Individual patient care planning is facilitated by the information system

The 2006 Collaborative is focusing on Prevention of Diabetes and Cardiovascular Disease

·        With the advent of the 2006 Collaborative, 100% current Community Health Centers in Iowa and Nebraska will be participating in one of the Health Disparities Collaboratives

The Future of Health Disparities Collaboratives

·        Work is underway to develop a primary health care collaborative

·        BPHC goal is 16 million patients by 2010

For more information about HD Collaboratives in Iowa and Nebraska, contact:

Jeanne Duquette, Chronic Care Manager,

Email: jduquette@ianepca.com

Phone: 515-244-9610

www.healthdisparities.net