Applying the Care Model in statewide health disparities collaboratives

The Massachusetts League of Community Health Centers, in partnership with the Massachusetts Diabetes Prevention and Control Program, Boston Public Health Commission, MassPRO and the University of Massachusetts Medical School, recently convened a state-based chronic disease quality improvement program in 17 community health centers across the state called the Massachusetts Health Disparities Collaborative. In Phase 1 of this 13-month state-based quality improvement effort, modeled after the National Health Disparities Collaboratives, community health centers have focused on achieving strategic system change in the delivery of primary health care for patients living with diabetes by applying the Care Model. Helping patients living with a chronic health condition to manage their disease is a central tenet of the Care Model, an evidence-based conceptual framework developed by Wagner and colleagues (Wagner EH et al, 2001, Epping-Jordan JE et al, 2004). Each of the 17 community health centers' multi-disciplinary diabetes team tracked multiple core national diabetes health measures for approximately 100 patients living with diabetes. Core national measures tracked over time for the population of focus include: average HbA1c; percent of patients with 2 HbA1c in the previous 12 months at least 3 months apart; percentage of patients with blood pressure less than 130/80; percentage of patients with low density lipoprotein less than 100; percentage of patients on cardiac risk reduction medications (i.e., statins, ACE inhibitors or ARB, and aspirin or other antithrombotic agent); and self management goal setting. Degree of improvement in core national measures over time will be compared to selected characteristics of individual community health centers including: 1) team structure, as measured by staff turnover, size, and individual team member interview; 2) community health center organizational infrastructure, as measured by Assessment of Chronic Illness Care survey; 3) community health center internal and community resources; 4) monthly self-assessment scores tracking progress in the collaborative as measured by defined standards and ; 5) population of focus patient tracking method (previous electronic medical record use versus introduction of tracking method for participation in the collaborative). This presentation will describe attributes of community health centers and collaborative teams that may contribute to greater improvement in core national measures for patients living with diabetes, as well as support sustainability. Understanding the characteristics of community health centers that may facilitate increased progress in patient health outcomes can inform future statewide collaboratives.