Chronic Care Model: A Quality Improvement Collaborative

Chronic diseases such as diabetes, hypertension, asthma and childhood obesity make up a big percentage of the underserved patient population at QueensCare Family Clinics. The Diabetic Registry has been an ongoing data collection tool used to show comparative outcomes. By using PECS (Patient Electronic Care System), key clinical indicators can be measured and tracked over time.

Dr. Joana Catalasan is QFC's physician champion for diabetes. In 2004, the Chronic Care Model got its start in the clinics using Dr. Catalasan’s diabetic patients as the population of focus. It was later expanded to the other clinics in 2005 with all 5 clinics on board by October 2005. The number of patients registered in the program has grown from 35 to 2,684 patients as of mid-June 2008. Health Resources & Services Administrations’ (HRSA) goal is to have 18 million diabetics across the nation entered into a Registry by 2010.

Edna Bush, RN, CCM, Director of Disease Management, collects the patient data on a monthly basis then submits a summary as well as a narrative report on the 6 components of the Chronic Care Model upon which the disease management program at QFC is based upon. In addition, clinic providers use them to help each patient control their own disease and improve their quality of life.

Our partners in collaboration are the Community Clinics Association of LA County (CCALAC), the California Primary Care Association (CPCA), Health Disparities National Collaboratives (HDNC), and soon the Los Angeles County Department of Health Services. CCALAC will reactivate audits among their member clinics in 2008. The audits will measure specific indicators not only for diabetes, but also hypertension and adult asthma.

The advent of Electronic Health Records has proven to be extremely time saving for case managers entering data into PECS.