- Tailor the Chronic Care Model and team based care to solo
and small group practices. The Chronic Care Model creates greater
opportunity for the clinician to provide the best care to his or her
patient and empowers the patient to assume greater responsibility for
managing their health. The model was designed to work in large medical
groups and clinics with a number of systems of care in place. We will
have the opportunity to adapt this model to smaller offices where the
systems are not always robust in their ability to track and manage care.
We will also be bringing in the community resources as a key component
of team based care. For these offices, the team often resides in the community.
- Ensure that this model is culturally appropriate utilizing the knowledge
and experience of ethnic physicians who practice in solo and small group
practices. This project enables us to bring the experiences of ethnic physicians,
through the Network of Ethnic Physician Organizations Project, into the planning
and implementation of quality diabetes care. Ethnic physicians will be working
together with their white colleagues sharing their expertise in working within
their communities to improve care and empower patients to better manage their
health and the health of their family. We have the opportunity to really
evaluate how improving diabetes quality care can also reduce health disparities.
- Strengthen the Information Technology [IT] capabilities of solo and
small group practices to better monitor and track diabetes care. We will
begin our process by conducting an Office Technology Assessment with each
participating physician office. We will evaluate the systems currently in
place to track patient care, record patient information and communicate
with patients about their diabetes care, including the type of diabetes
registry tools available.
As a result of the CMA Foundation Advancing Practice Excellence in
Diabetes, primary care physicians will -
- More appropriately screen and treat individuals at risk for type 2 diabetes.
- Work in a team approach and utilize community resources to
assist families with diet, physical activity and management of type 2 diabetes.
- Share clinical best practices among practicing physicians, physician
organizations and other provider groups.
Problem Statement
Primary care physicians provide 75% of diabetes care and solo practice
physicians and physicians in solo and small group practice provide a
significant amount of this care. 46% of primary care physicians work
in these small office settings, creating challenges to implement the
chronic care model and team care approach for diabetes care. In California
1.5 million or 5.9% of adults have been diagnosed with type 2 diabetes
and it is estimated that an additional 600,000 diabetics are undiagnosed.
There is increased prevalence of diabetes in ethnic communities, with the
highest rate in the African American community at 10.3%, American Indian/Alaska
Natives at 9.3% and Latinos at 6%. While no data has yet been tabulated
on the prevalence of diabetes in the Hmong and Southeast Asian community,
clinicians in California are seeing a dramatic presence of type 2 diabetes
among their Hmong, Laotian and Cambodian patients.
Ethnic physicians are therefore critical partners in addressing diabetes
quality care. Ethnic physicians are more likely to practice medicine in
communities with a higher percentage of ethnically diverse members, which
improves the communities’ access to care. Minority patients are more
likely to choose providers of their own ethnic background, resulting in
greater patient satisfaction and improved outcomes. While most minority
patients in California still receive care from a provider of a different
ethnic background, ethnic physicians in California provide a bridge to
greater language and cultural understanding between their medical colleagues
and communities.
Program Description
Three communities have been selected to initiate the Small Physician
Office Collaborative. Criteria used to select these regions include
prevalence of type 2 diabetes, prevalence of diabetes complications
and diabetes death rates, each of which provides the opportunity to
improve diabetes quality care. Also considered was the ethnic diversity
of the population. Diverse populations provide the opportunity to
address the disparities associated with type 2 diabetes. Areas selected
are San Joaquin County, San Bernardino County and Butte/Glenn Counties.
Between 15 and 20 solo and small group practices will be recruited
to participate in each of the regional collaboratives. These physicians
will identify an ethnically diverse diabetes patient sample to participate
in the collaboratives. Each participating office will create a measurable
quality improvement plan. The principles of team-based care will be
utilized to provide community based organizations and other health providers
the opportunity to work together with primary care physicians to increase
access to the resources available for physicians in small medical office
settings and within diverse communities.
Goals
Overall goals of this multiyear project include -
- Demonstrate improvement in the quality of care provided to
a diverse diabetes patient population.
- Primary care physicians will more aggressively screen their patients
at risk for diabetes, resulting in earlier identification.
- Primary care physicians will understand the chronic care model
and team based care as it applies to diabetes care and apply these
to the small physician office setting.
- Solo and small group practices will grow in their capability
to track and monitor diabetes care.
- Team care and the chronic care model will be applied in a
culturally appropriate manner.
- Best practices associated with providing quality diabetes
care in a manner that can reduce health disparities will be shared
among physicians and other healthcare providers.
CMA FOUNDATION COMMITMENT TO PARTICIPATING PRACTICES
The CMA Foundation makes the commitment to over a two year period to participating practices:
- Offer physicians eight CME training sessions over a two-year period.
- Assist physicians and their staff with developing a Practice Care Plan.
- Assist physicians with readiness for Pay-For-Performance.
- Provide on site and telephone support during the project.
- Provide on site in-service training for staff in diabetes care
coordination and practice redesign techniques.
- Conduct initial data extraction of 35 patient records to
serve as a baseline and enter this data into the patient registry;
provide reports on patient tracking when requested.
- Provide online patient education materials that are culturally
appropriate as well as a CD master file of key materials to use in the office.
- Provide an online directory of professional and community resources available to
support patient care.
Advancing Practice Excellence in Diabetes
We know the number of people with diabetes is on the rise.
We also know that solo or small group physicians care for most of
these patients. This is why we are coming to you. We believe that
working with physicians who have made a life long commitment to work
directly within their communities is where we need to go to effectively
stop this epidemic and its consequences.
We also know that treating this disease is time intensive, and requires
much more from a practice than what is required for an acute care visit.
And that’s why we’ve initiated this project.
ADVANCING PRACTICE EXCELLENCE IN DIABETES is a project specifically
designed for the solo and small group practice. The project is unique
because it both increases the capacity for diabetes care management, and
it supports practice changes that makes sense for the solo and small group practice.
Our goal is to assist you and your practice in implementing a Practice
Care Plan based on the well-known Chronic Care Model – an evidenced based
process for increasing practice capacity and improving outcomes for patients
with diabetes. Our two-year commitment is to provide you with an advisor
to support your project implementation, and to supply helpful tools and
resources to you, your staff and your patients.
Participating in ADVANCING PRACTICE EXCELLENCE IN DIABETES can help
you design simple solutions that bring lasting and positive outcomes for
your patients with diabetes, for you and your staff, and for your community.
Contact Denise Torres, Project Director, at (916) 551-2868 or
dtorres@cmanet.org for more information.
Together we can make changes that make a difference!
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