| Excellence in Practice is one of the three basic elements in the Bureau of Primary Health Care (BPHC) strategy to reach its goals for ensuring access to quality primary care and moving towards the reduction of health disparities. Excellence in Practice represents a systematic approach that permeates the whole organization, its vision, mission, values and policies. It includes process design, performance measurement as well as improvement at both the individual and population level. Excellence in Practice is also one of the basic strategies for the BPHC to pursue the six aims for improvement outlined in the Institute of Medicine report, Crossing The Quality Chasm: A New Health System for the 21st Century. These aims outline a health system that is safe, effective, patient-centered, timely, efficient, and equitable.
This commitment to excellence also addresses a comprehensive range of issues. Strengthening governing board capacity to develop and implement an overall quality improvement strategy is fundamental. Community collaboration and coordinated care based on patient needs and characteristics are the centerpiece of a health center. The design of care processes and the effective use of information technologies are also necessary to transform health center practices. The development of effective teams and leadership, and a clinical, administrative, financial workforce with outstanding knowledge and skills are prerequisites for an effective quality strategy.
In addition, quality improvement and performance measurements are critical elements for excellence and for survival in the health care industry and marketplace. The environment is driving the use of data to increase accountability, support quality improvement, facilitate and support clinical decisions, monitor the population’s health status, empower patients and families to make informed health care decisions, and provide evidence to eliminate error and wasteful practices. These trends have recently been summarized in two Institute of Medicine Reports, To Err is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century. In addition, Federal and State governments as well as private purchasers require programs to document performance improvements as conditions for continued support or reimbursement. To meet these challenges and to move toward the elimination of health disparities, requires health care organizations to change the way health care is delivered. To help realize its Excellence in Practice goals, the BPHC initiated its Health Disparity Collaboratives in 1998. The Collaboratives strategy transforms practice through care, improvement and learning models; supports national, cluster and State infrastructure to support, sustain and spread positive change; engages and develops national and local leadership; and fosters partnerships at the national, State and local level.
Since 1998, interdisciplinary teams from 350 health centers have participated in collaboratives that have changed practices and improved health outcomes for patients living with diabetes, cardiovascular disease, asthma and depression. The proactive population-based Care Model, tested and implemented through participation in a Health Disparities Collaborative, requires knowing that patients have an illness or need preventive services, ensures delivery of evidence-based care, and actively aids patients and families to participate in their own care. Transforming practices to embrace this evidence-based model requires the leadership and support of health center senior management and the use of an effective improvement model that applies knowledge through rapid testing of changes and implementation of the successfully tested changes throughout the health care organization.
The implementation of the Care Model, assisted by a supportive learning community, has resulted in the improvement of nationally shared process and health outcome measures in diverse community health center settings and populations. Partnerships demonstrating national support of the collaboratives continue to flourish with the Centers of Disease Control and Prevention (CDC), State diabetes control programs and health departments, the Substance Abuse and Mental Health Services Administration, Environmental Protection Agency, National Institutes of Health/National Cancer Institute, National Association for Community Health Centers, Institute for Healthcare Improvement, the Robert Wood Johnson’s Improving Chronic Illness Care Program, and other private organizations. The ability to measure the impact on health care systems, community/State partnerships and health outcomes has been a driving force in the success of the collaboratives. There are currently more than 51,700 health center patients entered in chronic disease information systems that provide timely information to improve the care of individuals, in addition to reporting on the status of populations of patients with chronic illnesses. There are 40 CDC-sponsored State health department diabetes programs engaged with health centers that are participating in the collaboratives. Average HbA1c levels have decreased from 9.2 to 8.5 in more than 12, 200 patients in the Diabetes 1 Collaborative and from 8.9 to 8.3 in more than 22,000 patients in the Diabetes 2 Collaborative. Since beginning the Cardiovascular 1 Collaborative in April 2001, 43 percent of 4,700 patients with cardiovascular disease have a documented blood pressure less than 140/90. This represents a 20 percent improvement in blood pressure control in 5 months.
The Health Disparities Collaboratives are a fundamental BPHC strategy to implement and sustain major elements of health center program expectations. There are six key elements of the care model which forms the foundation for the Collaboratives.
Continuous Quality Improvement and Performance Measurement are critical elements in the program expectations. Responsibility and accountability for planning and implementing quality health care are outlined in the quality, management and board expectations. The Collaboratives, with their focus on high prevalence and high cost medical issues for the underserved and with their use of effective care, quality improvement and learning models and office design concepts addresses these expectations. The emphasis on the management team, leadership and organizational commitment to quality is also a key element in BPHC policy. In addition, both the care and improvement models enable health centers to organize and deliver required services, such as primary and preventive care, as well as enabling services, such as case management and outreach, in an effective and efficient manner. The collaboratives build the health centers reputation for quality in the community, facilitate accreditation, and in some instances, have led to increased reimbursement and access to more local resources.
Health centers must collaborate appropriately with other health care and social service providers and should collaborate with other local and State entities as well, such as health departments, community and faith organizations. The Collaboratives help equip health centers to engage in such partnerships. Examples include close relationships with State diabetes control programs, helping to improve asthma care in partnership with schools, and educational and support groups in collaboration with faith organizations.
The rights and responsibilities of people obtaining care at health centers are another key element of the Program Expectations. The Collaboratives support both clinicians and patients in taking an active role to improve health, to strengthen the strong relationship between patients and clinicians and reinforce the critical role consumers play in safeguarding their own health. Strategies to identify and support patient health goals, to provide encouragement and support to reach their goals, and to establish strong communication between patients and clinicians are key to the collaborative care model.
As part of their policies and procedures, health centers must have written clinical guidelines for the clinical staff which reflect the most current national standards. The Collaboratives close the gap between these evidence-based standards and actual practice. Through continuing professional education, medical record and information systems that prompt decisions based on clinical guidelines, and continuous assessment of outcomes, the clinical staff gains understanding and support to apply the most up to date science to the care of patients.
Health centers must have systems of care that are efficient, responsive to the needs and cultures of patients and that improve the health status of the patient population. Through the design and implementation of proactive planned visits, group visits, outreach such as promotoras and, in some cases, promoting relationships and communication with patients through the telephone or the Internet and other strategies, the Collaboratives facilitate effective and efficient delivery system design. In addition, principles of clinical office design generate practices where patients get exactly the help they want and need, exactly where they want and need it. This means designing the office to maximize access, facilitate productive interactions and teamwork, guarantee reliability and create a robust, financially secure, innovative, patient-centered practice where staff are valued and nurtured. Applying these design concepts, health centers have reduced the time patients spend in the health centers while increasing the time patients have with their clinician and increasing health center productivity. These office design principles are being integrated into the Care Model and the Health Disparities Collaboratives
Health centers must have a clinical information system. This includes a system which supports preventive and chronic disease management and feeds information and data into the health center’s quality improvement program. The Collaboratives provide technical assistance and software to help health centers with such systems. The software support is continually refined and updated to reflect health center needs.
The Collaborative care and improvement models are key elements in the multi-year BPHC strategy to improve health outcomes for underserved people. Consequently, the BPHC expects all health centers to participate in the health disparities collaborative program. This expectation includes successful completion of a year-long BPHC-supported or sponsored health disparities collaborative learning experience, or Phase 1, and the continued spread of the model, documenting and sharing core measures through monthly reports after the first year (Phase 2). In addition, eligibility or preference for many future funding opportunities focused on expansion of health center services, will require successful and continual participation in both phase 1 and 2 of the health disparities collaborative initiative. This includes continued submission of the senior leader report. Since participation in the Health Disparities Collaborative should be part of an organization wide-commitment, alignment of goals, and strategy and policies for quality improvement, the health center governing board must be actively involved as described in the Program Expectations.
Those health centers actively engaged in the health disparities collaborative are exempt from reporting audit data and goals from the 1991 Clinical Outcomes Measures in their grant application. However, these health centers are encouraged to use these measures and goals internally for performance improvement. In addition, many of these Clinical Outcomes Measures and goals will be incorporated in future collaboratives, such as prevention, cancer, and infant mortality.
Health centers in collaboratives are documenting outstanding results in diabetes, asthma, depression and cardiovascular care. Public and private partnerships at the national, State and local level have facilitated these outstanding results. Health centers will find that successful participation in the collaboratives helps in accreditation, including the new accreditation programs for chronic disease management, the Primary Care Effectiveness Review, and presenting an effective continuing or competitive grant application to BPHC. Outstanding health center results also aid health centers to compete for local and State opportunities. Moreover, these outcomes are recognized locally, nationally, and internationally. In the future, there will be new opportunities to work in other clinical areas, such as cancer and prevention, as well as diabetes mellitus, cardiovascular disease, asthmas and depression. For additional, updated information, and applications to participate, please refer to www.healthdisparities.net.
HRSA FIELD OFFICE CONTACTS
FOR HEALTH DISPARITIES COLLABORATIVES
FISCAL YEAR 2002
Boston – Region I
Lisa Dolan-Branton, RN
Regional Nurse Consultant
HRSA/Boston Field Office
JFK Federal Building,
Boston, MA 02203
Phone: (617) 565-1481
Fax: (617) 565-1162
Ldolan@hrsa.gov
New York – Region II
Roberta Holder-Mosley, CNM
Coordinator, New Jersey State Team
Regional Clinical Coordinator
HRSA/New York Field Office
26 Federal Plaza, Room 3337
New York, NY 10278
Phone: 212-264-2708
Fax: 212-264-2673
RHolder-Mosley@hrsa.gov
Philadelphia – Region III
Richard Vause, PA-C
Regional Clinical Coordinator
HRSA/Philadelphia Field Office
Public Ledger Boulevard, Suite 1172
150 Independence Mall West
Philadelphia, PA 19106-3499
Phone: (215) 861-4393
Fax: (215)861- 4385
Rvause@hrsa.gov
Atlanta – Region IV
Kim Willard-Jelks, MD, MPH
Coordinator for Clinical Affairs
HRSA/Southeast Field Office
61 Forsyth Street, SW, Suite
Atlanta, Georgia 30303-8909
Phone: (404) 562-4110
Fax: (404) 562-4119
KWillard@hrsa.gov
Chicago – Region V
Nancy Egbert, RN, MPH
Regional Clinical Coordinator
HRSA/Chicago Field Office
233 North Michigan Avenue, Suite 200
Chicago, IL 60601-5519
Phone: (312) 353-4204
Fax: (312) 886-3173
Negbert@hrsa.gov
Kansas City – Region VII
Lawrence Walker, DDS, MPH
Regional Clinical Coordinator
HRSA/Kansas City Field Office
601 E. 12th Street, Room 1728
Kansas City, MO 64106
Phone: (816) 426-5226, EXT. 251
Fax: (816) 426-3633
LWalker@hrsa.gov
Dallas – Region VI
Robert A. Sappington, DMD, MPH
Regional Clinical Coordinator
HRSA/Dallas Field Office
1301 Young Street, 10th Floor
Dallas, TX 75202
Phone: (214) 767-3719
Fax: (214) 767-3902
Rsappington@hrsa.gov
Denver – Region VIII
Vernon A. Maas, MD, MPH
Regional Clinical Coordinator
HRSA/Denver Field Office
1961 Stout Street, Room 409
Denver, CO 80294-3538
Phone: 303-844-7875
Fax: 303-844-0002
VMaas@hrsa.gov
San Francisco – Region IX
Winston F. Wong, MD, MS
Chief Medical Officer
HRSA/San Francisco Field Office
50 United Nations Plaza, Room 307
San Francisco, CA 94102
Phone: (415) 437-8141
Fax: (415) 437-8003
Wwong@hrsa.gov
Seattle – Region X
Richard L. Rysdam, DO, MPH
Regional Clinical Coordinator
HRSA/Seattle Field Office
2201 Sixth Avenue, MS 23
Seattle, WA 98121
Phone: (206) 615-2263
Fax: (206) 615-2500
RRysdam@hrsa.gov
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