Craig Brammer
Director,
Cincinnati AF4Q

A group of area primary care practices has been working together for more than a year in a bold effort to drive improvements in diabetes care across Greater Cincinnati. One of these innovative practices is Zile Family Health Care in Hillsboro, Ohio. This group has changed the way they deliver care in partnership with Cincinnati Aligning Forces for Quality (AF4Q) with promising results. The percentage of diabetic patients receiving necessary foot exams, eye exams and micro-albuminuria screenings has increased significantly since AF4Q began. Diabetic outcomes have improved, and more patients are meeting key medical parameters than last year.

In this second Progress Report on AF4Q I will update you on the activities and significant progress made by these forward-thinking practices that have been involved in AF4Q's Primary Care Innovation Group (PCIG) since its February 2008 launch.

Medical students master a myriad of concepts, skills and techniques during their training but quality improvement is not typically among them. Throughout their careers, physicians stay abreast of up-to-date drug therapies or surgical procedures, but traditionally there have been limited opportunities for participation in community-based quality improvement and measurement efforts. Aligning Forces for Quality is engaging key stakeholders to combine and share their expertise and is bringing the kinds of quality improvement strategies developed in the manufacturing world to the medical office.

Supporting Quality Improvement

The PCIG is a consortium of 11 primary care practices that represent a variety of settings from urban to rural, along with three "safety net providers," including a Federally Qualified Health Center, a Cincinnati Health Department branch in Price Hill, and a training site at the University of Cincinnati.

These innovative providers are applying the Chronic Care Model, developed by the MacColl Institute for Healthcare Innovation (IHI), to the care of patients with diabetes in their practices. They are optimizing protocols and data management techniques that are already showing a positive effect on patient care quality and office operation efficiency for physicians. Many of the participating practices had already begun their journey to improve patient outcomes. AF4Q has provided a necessary coordinated framework for measuring, reporting and improving quality with an ultimate goal of driving much needed health care change.

In support of participating practices, AF4Q has expanded and coordinated quality efforts as follows:

• Identified nine measurable parameters that define high quality care for diabetic patients and set goals for those parameters
• Provided training in quality improvement based on the Chronic Care Model as well as The Model for Improvement and the IHI Breakthrough Series. AF4Q also provided a Toolkit that helps physicians to assess quality in their practices and move toward improvement.
• Helped practices develop a registry, or electronic medical record (EMR) system with registry functionality, used to track and summarize patient data
• Conducted quarterly learning sessions and conference calls which bring the experience of national experts to the group (check out the PCIG video to see what a typical learning session is like)
• Offered a practice coach who can visit an individual site to troubleshoot quality improvement

In this first year of activity, participating practices have streamlined office protocols — conserving resources and creating more time for doctors to spend with patients. They have implemented or enhanced their use of electronic records, making patient data more easily located, and making it possible to track practice-wide improvements in measured parameters. Aggregate data are reported to AF4Q on a monthly basis.

Real Patients, Real Results

Patients at Zile Family Health Care are receiving more of the screenings they need, and they are more frequently meeting key medical parameters. Changes within the office have made it easier for patients to:

• Receive more comprehensive care
• Increase participation in their own care

But the benefits of Zile Family Health Care's participation in AF4Q do not end there. Ron Zile, MD, is working in conjunction with two certified nurse practitioners to restructure the approach to chronic disease management.

• Dr. Zile is finding the time he spends with his patients to be more productive.
• Patients are now asked to have blood work completed before their appointments.
• Up-to-date results, along with other important data, are readily available in EMR summaries.
• Foot exams are performed by nurses or MAs, freeing Dr. Zile to give attention to problems that have been identified.
• EMR queries identify patients needing additional support within measurable parameters such as diabetic eye exams.

A team approach and practice redesign allows Dr. Zile and the office staff to help patients with self-management, which significantly impacts successful care for chronic disease.

Mary Zile, BSN, MHSA, has helped the office adopt an enhanced team approach to care. She has provided educational opportunities that empower nurses and MAs to take more responsibility, and conducted group discussions that make quality improvement a priority. A wall chart Mary designed demonstrates the link between lower HbA1c levels and patient morbidity and mortality, bringing home the tangible results of the work they do. Systemic and process changes have allowed great employees to become even better and strengthened their role in improving patient outcomes.

A Model for Quality

The story of Zile Family Health Care has been retold in PCIG practices across the Tristate. Collectively, between March and December, these practices have seen positive improvements.

At this program's conclusion in the fall of 2009, AF4Q will be in position to spread the learnings of the PCIG to the wider community. The model for diabetes care that is being developed here in Greater Cincinnati will already have a quantifiable track record. As this model is in alignment with the concept of the patient-centered medical home, practices that adopt it will be well-positioned as certification programs become available. The hope is that designation as a patient-centered medical home will one day bring increased reimbursement from health insurers.

I look forward to meeting with PCIG participants this fall, as we gather to share our learnings and celebrate the progress we have made toward a future in which diabetes care is practical, equitable, reliable and affordable. Cincinnati AF4Q will then turn its attention to planning how to adapt the diabetes model to the care of other chronic illnesses.

Craig Brammer