Implementation of HIT-Facilitated Diabetes Care Coordination Assessment for Ambulatory Care Providers

The Beacon Community of the Inland Northwest (BCIN), a Beacon Community Program funded by the Office of the National Coordinator for Health Information Technology, is a care coordination (CC) project that is utilizing health information exchange (HIE) to assist providers from separate organizations across a large geographic region to share health information on adult patients with type 2 diabetes (DM2). An initial step in implementing CC involves assessment of existing resources and services to support comprehensive diabetes care coordination, as well as gaps in such services and resources. We have developed and implemented a Diabetes Care Coordination Readiness Assessment (DCCRA) for such a purpose. Our results indicate wide variability in readiness of primary care clinics across the Spokane Hospital Referral region to initiate care coordination services. Results of the CCRA are characterized by the type of ambulatory care setting and BCIN resources needed to support clinical transformation, care coordination, care management and quality improvement at each participating clinic. The assessment results assisted BCIN and clinic staff in the examination of clinical resources specific to comprehensive diabetes care management. To support primary care clinics in moving toward functional care coordination capability the BCIN has implemented resources to support clinical transformation including web-based learning modules, in-person training sessions, on-site coaching services, work flow analysis and re-design, application of clinical standards with best practices and technology support to facilitate two-way, real-time sharing of electronic health information. These methods have been applied across a rural/urban catchment area involving 376 providers in 36 clinics and affecting over 56,000 patients with DM2. This work has led to an understanding of the elements that contribute to a clinic's readiness for care coordination and how to apply CC on a large scale across multiple clinic settings.