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Health centers improve diabetes care, results

Community health centers can play a key role in reducing health disparities, but it takes more than simply opening a center in a medically underserved neighborhood. In order to bridge the racial and ethnic gap, strong leadership, a long-time commitment, adequate resources, and proper incentives are required, says Marshall Chin, MD, MPH, an associate professor of medicine at the University of Chicago and coauthor of the recent study Improving and Sustaining Diabetes Care in Community Health Centers with the Health Disparities Collaboratives.

Chin and seven other researchers wrote the study, which was published in the December 2007 Medical Care. They reviewed 34 Midwest and West Center cluster community health centers that participated in either the first or second Health Resources and Services Administration’s Bureau of Primary Health Care (BPHC) Diabetes Collaborative initiative to improve diabetes care.

BPHC oversees the country’s 5,000 community health centers that are improving care of the medically underserved through Health Disparities Collaboratives (HDC). Sixty-eight percent of the health centers in the HDC chose diabetes as their target disease, namely because of the difficulty of caring for patients with diabetes and its impact on ethnic and lower socioeconomic populations. “Diabetes is a paradigmatic disease for chronic care management,” wrote the study’s authors.

The study looked to answer two major questions about the HDC:

What impact does the HDC have on care and outcomes related to diabetes over a sustained period?

What is the effect of varying the intensity of the intervention? Do more intensive quality improvement (QI) efforts that incorporate organizational change, provider behavioral change, and patient empowerment improve care further?

Researchers discovered improved diabetes care and results over a five-year span (1998–2002).

Hemoglobin A1c and LDL levels decreased, whereas diabetes care standards improved, including A1c tests and lipid assessments, foot and eye exams or referrals, and aspirin use.

The study also showed the importance of perseverance. Although test-taking improved at the two-year mark of the study, it took the full four years to show improved test results. Chin says this is because it takes longer to see health improvements than simply improving care. The authors noted the “importance of enduring commitments to the QI intervention and long-term outcome studies.”

The health centers used a Model for Improvement developed by Associates in Learning called the Plan-Do-Study-Act cycle. They also used the MacColl Chronic Care Model that was created by Group Health’s MacColl Institute for Healthcare Innovations in Seattle. The Chronic Care Model has six target areas:

  • Patient self-management
  • Information systems
  • Decision support
  • Community outreach
  • Leadership organization
  • Effective delivery system

“Its ultimate goal is to improve the quality of care and outcomes by having activated, empowered patients working with a proactive team of doctors, nurses, and administrators,” says Chin.

According to the authors, the study’s “important implications” for health centers are: a powerful governmental organization can “facilitate sustained QI in a national network of generally highly motivated, idealistic [health centers] by training, lending assistance, and conveying that the QI collaborative approach should be done . . . The rapid QI approach and Chronic Care Model are paradigms that allow flexibility. [Health center staff is] used to working creatively in resource-constrained environments.”

“There is a very positive message that when there is the will, the mission, and the leadership, and support in the overall program, you can make dramatic improvements in terms of quality and outcomes for diabetic patients even under very difficult circumstances,” says Chin.

Chin says he figured the researchers would see care improvements but knew the centers faced challenges because of limited resources and patient population (poor, little education, and many without insurance). In fact, approximately one-third of the patients in the centers studied did not have health insurance, and about one-quarter were on Medicare.

Standard vs. high-intensity intervention

In addition to determining whether the HDC improves diabetes care in health centers, investigators reviewed whether more intensive interventions enhanced care further.

The standard-intensity arm included:

An HDC team that met regularly with the support of senior administrative leadership

Tracking by each center of a registry of diabetic patients to gauge care

The introduction of a Model for Improvement developed by Associates in Learning to the centers

Support from the BPHC, including quarterly progress reports from the QI teams and senior leadership, conference calls with other centers, and cluster coordinators

Yearly in-person meetings with other health centers

The high-intensity arm included the above and:

Four 1.5-day learning sessions

Training in patient-provider communication and behavioral change techniques

Patient empowerment videos and brochures

Monthly conference calls

The more intensive intervention showed a mixed bag. There were increases in the use of angiotensin converting enzyme inhibitors and aspirin, but less documentation of diabetes education and dietary and exercise counseling. “These findings suggest tradeoffs between intensifying medication use and participating in diabetes education and dietary/exercise counseling,” wrote the study authors.

Chin says intensive interventions did not affect care as much as expected because the standard health collaborative is already “pretty intensive.”

“[The high-intensity arm] may help at the margin, but some of these ideas were already in the standard HDC . . . I think what this shows is you get a lot of bang out of the standard health disparities collaborative,” says Chin.

Although the study focused on health centers, the authors noted that other healthcare entities can learn from the report.

“More generally, motivated, hardworking healthcare staff can improve care and diabetes outcomes when given autonomy and support to create change.”

Six keys to bridge the disparity gap

Improving and Sustaining Diabetes Care in Community Health Centers with the Health Disparities Collaboratives showed how health centers affect care for the poor, but how do private insurers and DM companies reach that population?

Winston F. Wong, MD, MS, medical director of community benefit and director of disparities improvement and quality initiatives for Kaiser Permanente in Oakland, CA, provided these six keys to reduce health disparities for any healthcare organization:

  • Good data that highlight conditions affecting the specific population
  • Patient registries, at the very least disease registries
  • Bilingual, bicultural workers
  • Strong clinical leadership that sets the agenda for the clinicians
  • Partnerships with local and/or regional effort to improve care for vulnerable populations
  • Strong health educators and community health workers, including social workers and certified diabetic educators, that augment clinicians

Marshall Chin, MD, MPH, an associate professor of medicine at the University of Chicago and coauthor of the health center study, believes health plans, DM companies, and individual practices can learn from community health centers.

“I think the average practice can do an outstanding job also. I think for the health center, [caring for at-risk populations is] a larger priority. It’s very much on the radar screen. The health centers serve a large number of ethnic minorities and poor patients. It’s an integral part of the mission. Nationally, we’re seeing equity issues becoming a larger part of the quality debate,” he says.

Chin praises those who work at health centers for their open-mindedness and passion. Having a motivated staff that is not too large makes change possible. “One thing that centers have done very well is: how can you tailor to your own subpopulations? I think that the general message of tailoring to your specific population as opposed to just blindly using a one-size-fits-all approach is an important lesson of the collaborative,” he says.

Flexibility is important

Having a chronic care model in place is a helpful foundation to bridge the health disparities gap, but Marshall Chin, MD, MPH, an associate professor of medicine at the University of Chicago, adds that the community health center must be flexible to implement programs that best help their patient population.

Winston F. Wong, MD, MS, medical director of community benefit and director of disparities improvement and quality initiatives for Kaiser Permanente in Oakland, CA, says health centers are able to quickly tweak care to best serve their populations because they are not bound by hierarchical and clinical roles and position descriptions that are common in other areas of healthcare. Making changes are not as easy for a large organization that must deal with thorny labor and HR issues.

“You have to be willing to wipe the board clean at least in a pilot site or a microsetting where there is enough willingness on all parties to look at what people do in the clinic and have definitions that enable flexibility to occur . . . You first have to see the clean board and understand the needs of patients come first rather than the preservation of job titles,” says Wong, who was formerly the medical director at Asian Health Services in Oakland, CA, and a clinical officer for the Department of Health and Human Services’ Region IX, which included overseeing health centers in Arizona, California, Nevada, Hawaii, and the Pacific Basin.

Part of the reason why health centers are able to adapt and know their community so well is because these centers’ staff members are usually from the neighborhood and have risen through the ranks at the centers.

“The centers are such that for it to work you basically have to have buy-in from everyone. You need providers to be into it, the front-office staff, the senior leadership. You need an overall commitment and that kind of effort to do it,” says Chin.

With PCP and nurse shortages expected in the near future, Wong says he is concerned about the prospects for health centers that serve the most vulnerable.

“There is a looming threat of not having enough nurses and not having enough community-oriented primary care physicians to care for the populations. Whenever those things happen, all good work that has been done in regard to caring for patients with special needs gets undermined,” he says.