A network of nurse practitioner primary care practices serving underserved populations and the PA Governor's Chronic Care Initiative

The aim was to implement the six components of the Wagner chronic care model (Community, Health System, Self Management Support, Delivery System Design, Decision Support and Clinical Information Systems) for the redesign of practice for adult diabetic patients in a network of four nurse-managed primary care practices serving the homeless, public housing and immigrant farm workers. The baseline for performance of the Improving Performance In Practice (IPIP) goals for diabetes was June, 2008. These goal indicate very good care based upon national standards and include: Blood Pressure (<130/80 at >70%); Cholesterol (LDL <100mg/dl at >70%); A1C ( >9% at <5%); dilated eye exam (>80%); tested or under treatment for nephropathy (>90%); asked about smoking and if smoking counseled to stop (>90%); on statin ( >60%); over 40 on an aspirin (>85%); 55-75 yrs. of age on ACE/ARB (>75%); BP<140/90 (>90%); A1C<7% (>75%); at least one LDL (>90%); LDL <130 mg.dl (>90 %); foot exam (>90%); influenza vaccination (>75%); pneumonia vaccine (>90%) and documented self-management goals (>90%). Baseline measures and 3 month, 6 month, 9 month and 12 month measures will be shared along with the re-design of the practice network toward meeting the goals. The IPIP goals for this initiative are to be met within three years.