Indiana Primary Care Learning Collaborative: Population health in primary care

In 2010, approximately 50% of Indiana adults reported having a history of heart disease, stroke, cancer, chronic lower respiratory disease, diabetes, or arthritis. As a consequence, population health and prevention of chronic disease and associated risk factors in the primary care setting became a priority for the Indiana State Department of Health (ISDH). The ISDH developed the Indiana Primary Care Learning Collaborative (INPCLC) with emphasis on state-funded federally-qualified health centers (FQHC) as a pilot cohort (n=4).  The location of these clinics, both rural and urban, facilitated access to a wide-range of populations who are disproportionately affected by chronic disease, including African Americans, Hispanics, refugees, and individuals with low socioeconomic status.  The INPCLC focuses on patients with diabetes or hypertension, or who are obese or use tobacco. It also includes ways to increase primary preventive screenings, specifically for breast, cervical and colorectal cancer.  In order to improve outcomes, the INPCLC employed evidence based guidelines, the Chronic Care Model, and the Associates in Process Improvement’s Model for Improvement. Facilities tracked clinical and process outcomes on a monthly basis. Over the course of the collaborative, clinics increased the mean percentages of patients screened for tobacco use (+6.2%), tobacco users referred to the Indiana Quitline (+11.7%), and those referrals who registered with the Quitline (+22.4%).  FQHCs also increased the mean percent of children with a calculated BMI (+19.8%), and overweight adults (+13.7%) and children (+4.6%) with a shared care follow-up plan.  There was a decrease in the mean percent of diabetic patients with A1C>9% (-1.3%), and an increase in the percent of diabetic patients with LDL<100 mg/dl (+5.4%), a comprehensive foot exam within the last year (+9.1%), and a documented self-management goal within the last year (+47.4%).  Clinics noted that participation in INPCLC has increased efficiency in provider-to-patient face time, Meaningful Use reporting, and patient self-management engagement. Additionally, they observed a reduction in patients not showing for appointments, improvement in managing patient populations, and indicated benefits from peer-to-peer learning. In September of 2013, INPCLC launched Cohort 2 which consists of additional state-funded FQHCs, community health centers, and rural health clinics (n=29). The results of Cohort 2 data will also be presented in order to compare, strengthen, and emphasize results.