Project Overview

The first phase of Advancing Practice Excellence in Diabetes will strengthen the viability of solo and small group practices, and create a new model of care for treating chronic conditions.

Primary care physicians provide the most adult diabetes care, and in California, more than half of these physicians practice in small office settings. This project would like to reach out to the solo and small group primary care physicians to support and facilitate change within the small office setting.

The goals of this project are to:

1. Improve quality of care provided to a diverse diabetes patient population.
2. Encourage offices to aggressively screen patients at risk for diabetes, resulting in earlier identification.
3. Understand and apply the chronic care model and team based care in the office setting.
4. Support solo and small group practices in increasing their capacity to track and monitor diabetes care.
5. Share best practices associated with providing quality diabetes care.
6. Connect health care providers with educators and community resources through an online community resource directory.

• Increase the quality of care delivered to patients with diabetes by raising awareness of clinical outcomes in each patient through an electronic disease registry system or electronic health record system.
• Strengthen physician communication with their patients.
• Broaden physician and staff understanding of the health disparities and cultural differences associated with diabetes.
• Increase understanding of the link between diabetes and depression.

Through partnerships with health plans, local medical societies, community leaders, and physician leaders, the CMA Foundation will support physicians in their pursuit of preventing diabetes and minimizing its impact on their patients.

Pilot Projects
Three pilot communities have been selected using criteria that include prevalence of type 2 diabetes, prevalence of diabetes complications and diabetes death rates to initiate the project. All criteria provide the opportunity to improve diabetes quality care. Also considered was the ethnic diversity of the population which provides the opportunity to address the disparities associated with type 2 diabetes. The three areas selected are San Joaquin County, the Inland Empire [San Bernardino & Riverside Counties], and Butte/Glenn counties.

Solo and small group practices [less than 6 physicians] are being recruited to participate in each regional collaborative and to identify a diverse patient sample. Each participating office will create a measurable quality improvement plan referred to as a Practice Action Plan and will adopt a team care model within the practice to work toward accomplishing these goals. The basis of quality improvement in this project is to improve and evaluate office procedures and systems of patient care that will impact patient outcomes related to their diabetes. Practices are expected to work closely with community partners and share best practices with fellow physicians in the collaborative.