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APHA Scientific Session and Event Listing

Jenifer Fabian, MPH and Kathleen Gregory Guerrero, BS. Access Community Health Network, 1501 South California, Chicago, IL 60608, 773.257.5465, fabj@accesscommunityhealth.net

Chronic disease management, including diabetes management, represents a significant medical and financial issue for medically underserved communities. In 2004, Access Community Health Network (ACCESS) developed a comprehensive diabetes care management program to improve the quality of clinical services and reduce health disparities in diabetic patients.

The success of ACCESS' diabetes intervention is grounded in a strong planning model that was used to build and replicate strategies across our network of health centers. Based on a successful pilot project at six sites, ACCESS expanded its diabetes care management program to an additional 37 health centers, impacting 9,000 diabetic patients. Within one year, the number of patients receiving HbA1c tests every six months jumped from 60 percent to 91 percent and foot exams increased from 32 to 71.

The resulting care management model has improved the health of low-income patients with diabetes and demonstrates a replicable model for other chronic conditions that are prevalent among medically underserved communities. We will discuss the planning process, including integrating clinical care with revenue metrics, pay for performance strategies and community collaboration.

Learning Objectives:

• ·To identify an integrative planning model to address chronic conditions
• ·To identify clinical practice management tools
• ·To develop a sustainable model of care for chronic conditions
• ·To assess opportunities for revenue enhancement through improved patient care

Keywords: Community Health Planning, Chronic Diseases

Presenting author's disclosure statement:

Any relevant financial relationships? No