Chapter 1. Introduction
The aim of the Decreasing Disparities Strategy Workgroup of the Agency for Healthcare Research and Quality (AHRQ) is to reduce disparities in quality and/or access to care in priority populations through establishing improved methods of transferring knowledge from researchers to providers, purchasers, and policymakers. While the initial projects developed by the Workgroup may focus on a particular priority population and clinical condition, the expectation is that these projects will provide knowledge that can be used to decrease disparities experienced by other populations with other medical conditions.
Due to the rapidly growing number of Hispanics in many areas of the United States and their higher incidence of diabetes, the Decreasing Disparities Strategy Workgroup embarked on a learning network project to reduce the diabetes disparity in the Hispanic population. The Workgroup targeted community health centers with a predominately Hispanic population for this intervention, which was conducted from June 2006 to January 2007.
Delmarva Foundation performed a needs assessment among community clinics known to have a high percentage of Hispanics. The goal of this assessment was to learn what clinic providers perceived to be a significant gap between evidence-based practices and their current practices, what they felt could make a difference in patient outcomes, and what they were committed to change.
The clinics were familiar with Ed Wagner's Chronic Care Model1 and the benefit of patient self-management. Whereas patient education provides information and technical skills to help individuals manage their chronic conditions, the goal of self-management training is to enhance patient problem-solving skills. A central concept in self-management is self-efficacy, or patient confidence to carry out a behavior necessary to reach a selected goal. In a clinical setting the process begins with bi-directional communication between the provider and the patient to identify a goal important to the patient and the behavior changes necessary to achieve the goal. Patients must feel confident to make behavior changes, and this is why small incremental changes are often the target.
All the clinics noted their interest in improving their performance on interactive goal setting to assist patients in gaining self-management skills. Improving patient self-management aligns with creating patient-centered care, one of the Institute of Medicine's six aims for improving health care across all the chronic diseases and populations, and represents a major challenge for moving the quality indicators for ambulatory health care. Although only 7 months in duration, this learning network initiative offered an opportunity for clinics to begin process improvement on an important component of the Chronic Care Model.
The Decreasing Disparities Strategy Workgroup established clinic selection criteria based on readiness for change to increase the likelihood of success. The Workgroup also established criteria to achieve diversity to increase the knowledge that might be gained from the learning network initiative.
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Clinic Selection Criteria
During a needs assessment with the AHRQ Decreasing Disparities Strategy Workgroup, the focus of this project narrowed to improving care to Hispanic persons with diabetes in two types of diverse geographic regions. The following criteria were utilized to evaluate the final selection of these regions and the specific clinic participants for the study.
Readiness for Change Criteria
- The ability to identify Hispanic patients with diabetes.
- The capacity to improve patient self-management efforts.
- Clinical champion(s) for a patient self-management initiative.
- Commitment of health center leadership for participation of staff and the health center in efforts to improve patient self-management and the collection and submission of data to evaluate their interventions.
- Urban and rural clinics.
- Different subpopulations of Hispanics.
- Federally Qualified Health Centers (FQHCs) as well as community health centers without Federal funding.
The Workgroup recognized that the non-FQHCs might have less quality improvement training and experience but felt the potential benefit for patient care from their participation outweighed any disadvantages that might result to the learning network outcomes.
Delmarva recruited six clinics in two regions for the project. Three clinics are in rural and urban settings in Colorado and serve Hispanics predominately from Mexico:
- Clinica Tepeyac in Denver, Colorado.
- Mountain Family Clinic in Glenwood Spring, Colorado.
- People's Clinic in Boulder, Colorado.
The other clinics, which serve a high percentage of Hispanics from Central America, are in the District of Columbia metropolitan area. One clinic is within the District, and two are located nearby in Montgomery County, Maryland:
- Proyecto Salud in Silver Spring, Maryland.
- Spanish Catholic in Silver Spring, Maryland.
- Spanish Catholic in Washington, DC.
Clinic characteristics. Two clinics in Colorado were FQHCs, had a chronic disease registry, and had been involved in quality improvement collaboratives through the Health Resources and Services Administration (HRSA). A third clinic received no Federal funds, had no disease registry, depended a great deal on volunteer clinician staff and fund raising, and had a director who wanted to enhance their quality improvement efforts. All three clinics serve a population of 60 percent or greater Hispanics predominately from Mexico.
In comparison, none of the clinics in the District of Columbia metropolitan area was an FQHC. All of the clinics utilized the same chronic disease registry made available through HRSA. One clinic had a diabetes school, and the other two clinics shared a diabetes educator for office counseling and group classes. The Center for Healthcare Improvement of the Montgomery County Primary Care Coalition (PCC) provided quality improvement technical assistance and support for these clinics.
The range of diversity for the six clinics posed some problems for interpreting the results of the learning network. However, the diversity provided a richer set of observations and was a reminder that clinics have to design their own quality improvement strategies based on their resources and capacities.
1. The Chronic Care Model was developed by Ed Wagner, MD, MPH, Director of the MacColl Institute for Healthcare Innovation, Group Health Cooperative of Puget Sound, and colleagues of the Improving Chronic Illness Care program (www.ihi.org/IHI/Topics/ChronicConditions/AllConditions/Resources/ImprovingChronicIllnessCare.htm) with support from The Robert Wood Johnson Foundation.
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