2. Lessons Learned in All Components of Chronic Care Model (continued)

Table 9. Lessons learned in clinical information system

Clinical Information System

Tools/Steps	Resources	Tips/Lessons Learned
1. Disease registry was used in four clinics and data on diabetes were being collected, analyzed, and reported. For clinics without a registry or EMR, process had to be developed for capturing and monitoring data to measure progress on intervention.	HRSA provided software for this registry.	Manual data collection is so resource intense that clinics without automated data collection system will have difficulty monitoring and measuring progress for quality improvement projects.
2. Step for spread of intervention made by Primary Care Coalition (PCC) for Montgomery County. PCC was implementing EMR in its 10 clinics and decided to incorporate Action Plan into EMR to facilitate goal setting in all clinics.	EMR and resources to modify software

Table 10. Lessons learned in delivery system design

Delivery System Design

Tools/Steps	Resources	Tips/Lessons Learned
1. Glucose screening offered on demand in one clinic	Policy felt to increase blood glucose tests performed but can also increase laboratory costs for clinic.	Clinic felt this practice helped them diagnose diabetes earlier in many patients. For some who did not have materials to test their glucose at home, this policy provided alternative.
2. Scheduling patients for same provider was implemented for better continuity of care.	Appointment system designed and schedules of providers developed several months in advance to allow front desk to schedule patients for one provider except in emergencies.	Resulted in better provider/patient relationship for working together on disease control. Often less time was needed to review chart.
3. Team approach integrated into clinic flow.	Adequate staffing and/or reallocation of staff and duties necessary to implement team approach.	Regardless of approach used, clinician must be part of goal-setting process.
4. Assure team has basic skills for intervention.	Each clinic must assess team members and skill needs before determining resources necessary for training.	Teams already convinced of value of patient self-management and goal setting, but 1-hour on-site training session helped them improve interactive skills for process. Clinic teams had varying levels of experience with quality improvement process. Some clinic teams may need training on the Plan-Do-Study-Act (PDSA) model to understand and support need for data collection and analysis.
5. Promotoras can be effective team members.	Clinic needs funds to hire; funds often not available in areas with promotora training program. Clinics and agencies may share funding of program and/or promotora.	Promotoras with same demographics as patient are most effective (e.g., age, sex, culture). Outreach and home visits are possible, and they can work in both clinic and community. Supervision is required and level varies with responsibilities and training of promotora.
6. In one clinic telephone contacts have been effective alternative to clinic visits for followup and medication changes.	Registered nurse or other staff member is trained to make clinical assessments by phone.	Trained team member calls and reviews patient's blood glucose checks done at home and any symptoms. Depending on discipline of team member, level of training, and protocol, medication changes may be made with or without consulting clinician. This does not necessitate multiple trips to clinic and lowered HbA1c levels of a patient group from 10-11% to 6-7%.
7. Having HbA1c results available during clinic visit improves care and goal-setting interaction	Many clinics do not conduct HbA1c and other tests on site and patients cannot make two visits to ensure results are available for their visit. One clinic does HbA1c on site at visit though it costs more than to have vendor perform test.	For one clinic benefit outweighed cost: Better counseling and goal setting while patient is in clinic. Less urgent followup contacts needed due to lab results.

Table 11. Lessons learned in organization of health care

Organization of Health Care

Tools/Steps	Resources	Tips/Lessons Learned
1. Assure leadership commitment to quality improvement process and intervention.		Recognized clinic champion is helpful in making changes. When champion is also medical director, intervention is more likely to be successful. When champion is mid-level provider, physicians do not always follow lead even when success is demonstrated. Clinic and board quality improvement objectives lend support to interventions.
2. Begin implementation using full-time clinic staff.		Employed clinic providers are more likely to change their care practices than part-time volunteers.
3. Create culture of transparency for results both within clinic and with other clinics.	Providers are often resistant to transparency of clinician data because they do not trust accuracy. Being able to validate data is critical.	Many clinics have difficulty profiling providers because patients may see multiple providers. This is another reason to attempt provider continuity in scheduling. Providers respond to feedback when shown that another provider is having far better outcomes with patients.

Table 12. Lessons learned in community

Community
Tools/Steps	Resources	Tips/Lessons Learned
1. Determine available resources in community for use by clinic or patients.	American Diabetes Association (ADA) has free materials and services. State and local health departments may have chronic disease and disparities funds. Community agencies sometimes work together to develop or fund promotora program and may even share time of promotora. In areas with large percentage of Latinos, hospitals may have bilingual nutritionists or certified DEd. National Kidney Foundation has partnered with communities for screening programs and Kaiser has partnered to provide assessments after health fair screenings. See delivery system for mental health services.	Although ADA's Por Tu Familia program is well known, it is not evidence based. Involving State health department program staff can help in having resources for spread after learning sessions. Seldom does clinic have resources to train and supervise promotoras but working together in finding resources can be answer. Some academic centers in areas with many Latinos have a training program. Some hospitals may have primary care clinics to decrease use of emergency departments and hospitals and provide free services.
2. Make clinic feel like part of Latino community to patients. Classes at night or on Saturdays may be held in places that will promote comfort and are easily accessible.	Requires no extra resources but cultural understanding and true caring on behalf of staff.	Latinos are more likely to keep appointments and attend classes if they feel comfortable in setting.

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3. Potential for Spread in Clinics

Four of the six participating clinics met the following criteria for being successful in maintenance and spread:

• Demonstrated data collection capability.
• Integrated a process into clinic flow to support patient self-management goal setting for diabetes and other chronic diseases.
• Clearly understood and supported the quality improvement process.
• Planned a process for measuring outcomes (measuring impact of goal setting on HbA1c).
• Planned to use the intervention for another chronic disease (modifications of Action Plan for all chronic diseases and obesity, adding hypertension as the next chronic disease, or integrating the Action Plan into the new EMR).

One additional clinic (Clinic C) reported that after implementation of the EMR, it was developing plans to evaluate the effectiveness of using the Action Plan in the diabetes school.

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4. Plans and Likelihood of Regional/National Spread

District of Columbia Metropolitan Area

The Montgomery County PCC has 10 community health clinics in its network. During the intervention, it began implementation of an EMR. The following is planned for this region:

• The PCC is integrating the Action Plan into the EMR.
• In September 2007, after implementation of the EMR, a patient self-management/goal-setting training session was conducted to train clinic champions from all 10 clinics and a PCC staff member. Those trained will become trainers in their respective clinics, with the PCC trainer providing support wherever needed.
• A pre-conference meeting was conducted by PCC and Delmarva with the medical directors of each clinic to achieve support for the training and the diabetes goal-setting intervention.
• Post-conference followup will be made by the Center for Health Improvement of the Montgomery County PCC.
• A Delmarva medical director is a member of the PCC Diabetes Advisory Committee and will continue to provide technical assistance.

Delmarva and the Mid-Atlantic Primary Care Association hosted a conference on May 17, 2007, to kick off a quality initiative for clinics in this multi-state region. Delmarva will help the Mid-Atlantic Primary Care Association develop its quality improvement strategy for diabetes and cardiovascular disease.

Colorado Region

• The Colorado Department of Public Health applied for a grant from the Centers for Disease Control and Prevention to conduct provider training on patient self-management for clinics using the Colorado Community Health Network staff.
• Colorado Community Health Network will expand provider training on patient self-management to its remaining 13 member health centers throughout Colorado.

Factors Facilitating Spread of Intervention

• Involving the county PCC and State Primary Care Association was crucial for spreading this intervention to other clinics in the two regions. These organizations were already investing resources in quality improvement efforts and can provide assistance and support for spread to other clinics.
• The efforts of the Montgomery County PCC to implement an EMR in all 10 clinics after this intervention facilitated the integration of the Action Plan into the EMR.
• Participation of the State health departments, specifically from the diabetes program or chronic disease prevention section, resulted in opportunities for spread. The level of resources available and even the opportunities for grant funds vary from State to State, but a closer working relationship between State and local health departments and community health clinics can be beneficial to all.
• Colorado has a foundation created from a conversion of a not-for-profit health facility that provides funding opportunities not available to many States or community health clinics. Clinics can use these foundations as a potential source of funds for EMR.
• Delmarva Foundation is the federally designated Medicare Quality Improvement Organization (QIO) for Maryland and the District of Columbia and can continue to support spread. A Delmarva medical director is a member of the PCC Diabetes Advisory Committee, and Delmarva is working with the Mid-Atlantic Primary Care Association on its quality improvement initiative on diabetes and cardiovascular disease. All States have a QIO that might have some resources for quality improvement efforts.
• The many efforts of HRSA to improve the quality of care in the FQHC have helped to lay the groundwork for similar quality improvement interventions. HRSA made the chronic disease registry available to clinics, hosted collaboratives providing an understanding of the quality improvement process, and placed materials and information on its Web site that have become a great resource to all clinics, even those that do not qualify for FQHC designation.

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5. Lessons Learned to Improve Care of Hispanic Persons With Diabetes

• Any written materials for Hispanics in community health clinics should be developed for a low literacy level; many may be illiterate and not volunteer this information. Simple pictures on materials and tools have helped to increase interest and understanding.
• Materials validated in Spanish may still be inappropriate for the clinic population if the concepts embedded are not familiar to the culture of the population being served.
• During this intervention clinics did not identify specific variances in the cultures of persons from Mexico or Central America that require a different approach in designing services.
• Hispanics are generally family oriented, and this is important for motivating them for lifestyle changes and compliance to a care plan. Parents may be motivated to take better care of themselves in order to better care for their children.
• Family members, preferably living with the patient, should be invited and encouraged to participate in classes for persons with diabetes. If the patient is male and there is a female in the home that prepares food, it is crucial to have this person present during classes and maybe clinic visits.
• Food is very important in this culture, and mothers may use it as a reward within families. Recognize the importance of food and seek healthier ways to prepare food. Often Hispanics are open to trying other ethnic foods that can provide variety and still be healthier.
• Many exercise options are not accessible or acceptable to Hispanics. Walking, biking, and dancing are common options used. Even walking can be hazardous in some urban settings. Work with the patients in interactive goal setting to see what is feasible for individuals.
• Hispanics often take the medical advice of a well-respected person in the community over that of the clinician in the clinic. Unfortunately, they usually do not discuss any differences of opinions with the clinician because he or she is an authority figure. For this reason it is even more critical for interactive goal setting with Hispanic patients to elicit what is important to the patient and what changes the patient is ready to make.
• Latinos will keep appointments and attend classes better if the environment feels a part of their culture and they are comfortable in it. Facilities that are old and crowded can be more successful than facilities that are more spacious and clinical in appearance if patients and their families feel comfortable and welcomed by people they trust.
• A myth exists in this culture that insulin can actually worsen the symptoms and complications of diabetes. The clinician must address why this myth exists (i.e., patients waited too long to start insulin and the damaging effects were already present) and why waiting can increase the complications of diabetes. However, clinicians should never intimate that patients who maintain good control will never have to use insulin. This can cause a trust problem since even patients with good control might eventually have to use insulin.
• When translating materials or discussing mental health issues with Hispanics, avoid using the term "depression." The term evokes a more negative response in this culture, and patients will deny having symptoms. Instead ask, "Do you feel sad more often; do you have trouble finding energy to do the things you usually do?"

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6. Lessons Learned Relevant to Other Quality Improvement Interventions

Evaluation of Learning Sessions

The primary purpose of the first Learning Session was the education and training of the participating health centers on patient self-management and activation for the Hispanic population. The participants' satisfaction surveys highlighted the value of discussion of implementation strategies, the redesign process to incorporate the tools, measures, and specific goals for each health center.

The second Learning Session provided an opportunity for the health centers to collaborate on issues and ideas for improvement, discuss individual progress by other participants, collaborate on similar barriers, and share practical improvement strategies.

Prior to the third Learning Session, a national conference call discussion was held with both regions. The third Learning Session was structured to encourage maximum sharing between all participants in both regions. Key concepts of the Chronic Care Model were utilized during the discussion to identify best practices for system redesign and spread.

The satisfaction survey remained the same for all three Learning Sessions and consisted of the following items, which participants rated on a 5-point scale (1 representing "strongly disagree" and 5 indicating "strongly agree"):

• This Learning Session was successful in sharing accomplishments and barriers faced by health centers while implementing this initiative.
• This Learning Session was successful in discussing different ideas for overcoming challenges of increasing patient activation and self-management goal setting.
• Receiving feedback from other health centers was valuable.
• Learning about how health centers in metropolitan Washington, DC, and/or Colorado are working on this initiative was valuable.
• This Learning Session helped me to consider next steps for my health center.
• Discussion on how to sustain and spread patient activation and self-management goal setting was valuable.
• This Learning Session helped me to consider ways to measure successes throughout this initiative.
• Adequate time was allocated for both presentations and discussions.
• The agenda of the Learning Session was valuable and productive.
• I am more confident and excited about the future of this initiative than I was before coming to this Learning Session.

Table 13 shows the results of the same satisfaction survey tool that was used for all three Learning Sessions. The survey was completed by all on-site participants for each session. The initial session presented education and training with the introduction of the project tools for use by the participant clinics. The second session facilitated collaborative sharing on improvement ideas and interventions, identified barriers, individual progress, and sharing of practical strategies. Before the third session, a national conference call took place with both geographic regions. Key concepts of the Chronic Care Model were used to identify best practices for system redesign and for spread concepts.

Table 13. Learning Session satisfaction survey results

Learning Sessions	Overall Score
1	4.0
2	4.3
3	4.4

Rating Scale: 5 = Strongly Agree; 4 = Agree; 3 = Neutral; 2 = Disagree; 1 = Strongly Disagree.

Lessons Learned by Faculty

• Although 6 months may be adequate for clinics to take an intervention from planning to institutionalization, the short time period can be a challenge even for clinics with more resources, experience with the quality improvement process, and strong support from leadership and clinic champions. Additional followup and study are needed to document that sustainability can be achieved within 6 months. Most clinics will need longer than 6 months to plan, implement, monitor, adjust, and institutionalize an intervention.
• The overarching goal of any learning network should be that participants understand the basic steps of the quality improvement process and can apply them to future clinic performance issues.
• Clinic demands limit the time staff can be away for training or participation in learning networks. Any alternative to decreasing the time away from the clinic should be considered, including:
  • Telephone conferencing for technical assistance.
  • On-site training or technical assistance for clinic team.
  • Virtual learning networks with only one off-site meeting required.
  • Online training or review of training for the basics of the quality improvement process.
• Selecting clinics with widely diverse characteristics, resources, data capabilities, and experiences with the quality improvement process may provide rich observations but inconclusive data relative to the impact of the intervention. Some clinic teams may be at too great a disadvantage for success when they start with greater challenges and the learning network is only 6 months in duration.
• Problem-solving discussions can be richer if faculty have:
  • Clinical experience similar to that of the participants.
  • Knowledge of and experience with the target population.
  • Fluency in the language of the target population.
• Tools validated in Spanish in the research environment may not be at the appropriate literacy level or based on concepts understood by the Hispanic clients of a community health center. When this is discovered, feedback should be given to the researchers.
• The likelihood for success of tools chosen for a learning network may increase if more time is dedicated to reviewing the science behind the tool and the best way to administer the tool. The Activation Assessment Tool was less familiar to the clinic teams than the Action Plan and needed more discussion and training before utilization was attempted.
• Flexibility in learning networks for use of a mandated tool can have positive results. One Colorado clinic during its planning stage recalled its experience with a tool similar to the Action Plan and decided not to use it. Instead, they changed their clinic processes to assure goal setting. This clinic had a significant increase in goal setting and also demonstrated a decrease in the average HbA1c level. Faculty of learning networks must consider the irony of requiring a paper form as a component of an intervention at a time when clinics are moving to electronic solutions for monitoring and tracking progress.
• Clinics that have a Hispanic population representing 25 percent or less of their patients may have different challenges than clinics with a predominately Hispanic population. The priority of the former is usually to find interpreters and bilingual staff. A well-developed Latino community may not exist to provide clinics and patients with support and services. The cultural competency is more difficult to achieve than in clinics with staff that are bilingual and of the same or similar culture.

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