Goal: Begin 12 month Diabetes Mellitus (DM) Collaborative III and Cardiovascular I with prework to begin in February 2001 and a first learning session in April 2001. The kick-off learning session in April includes 100 health centers and NHSC freestanding sites; with 50 health centers and 10-15 DCPs focusing on diabetes and 50 health centers focusing on cardiovascular disease.

Goal: Health Center and NHSC teams will complete the collaborative with an average team score of 3.5, meet the shared national project goals, with 90 percent of the monthly reports arriving on time each month, the cluster and national reports shared with all participants and partners by the end of each month, and with 100 percent of the participating sites completing the 12 month collaborative Note: Cardiovascular national project goals will be defined during the expert panel meetings.

Performance Expectations
PCA and CN

1. Shall provide travel and logistical support for 20-25 teams and a senior leader from each health center and NHSC site to attend the DM Collaborative III and Cardiovascular I kick-off learning session and the final national congress.
2. Shall provide travel and logistical support for two high performing teams from DM II and their senior leaders to serve as faculty and provide a poster session for DM Collaborative III and Cardiovascular I kick-off learning session and the final national congress.
3. Shall provide logistical support to organize and implement two cluster-based learning sessions, providing travel and support for 20-25 teams and their senior leader.
4. Shall collaborate with BPHC to pilot 3-5 "business case" measures in 1-2 volunteer diabetes sites per cluster (probably Relative Value Unit (RVU) based).
5. Establish and implement cluster strategy to sustain and promote high performing teams and improve performance for lower performing teams.
6. Support and facilitate implementation of State DCP and health center team aims and facilitate support from State and local cardiovascular initiatives with health center teams working on cardiovascular aims.
7. Collaborate with the BPHC and other clusters to develop an uniform application and selection protocol and recruit health centers and NHSC sites for the collaboratives. Recruitment and selection will target health centers that have not previously participated in a health disparity collaborative.
8. Select and enroll health centers including migrant, homeless and public housing primary care health centers for participation.
9. Provide revised orientation manual and technical assistance to teams during pre-work phase prior to April kick-off learning session.
10. Develop cluster strategy to utilize high performing teams in the collaborative.
11. With BPHC and IHI develop strategy to involve senior leader(s) in pre-work and monthly test cycles and assure that senior leadership attends April diabetes and cardiovascular kick-off with breakout session designed for leadership.
12. With national director, develop a strategy for involving coordinators and directors from other clusters in learning sessions and expanding faculty available to each cluster.
13. Promote participating sites enrollment in and use of the cluster listservs.
14. Have cluster directors attend the IHI National Forum in December 2001.
15. Collaborate with BPHC and CDC to identify additional State DCPs to participate in the collaborative.
16. With BPHC and other clusters, develop and implement a communication strategy that includes national and cluster specific information, highlights successful models and partnerships and is shared on a regular basis with partners, health centers, community groups, and patients. Utilize existing State or regional telecommunications systems where feasible.
17. Implement site visit, conference call and monthly report protocols with one section specifically set aside to address collaboration with DCP and other CDC-supported State partners.
18. In collaboration with national director, integrate cluster coordinators and directors as faculty in selected cluster learning sessions.
19. The Together for Tots (TOTs) State PCAs will submit Letter Of Intent with lead cluster PCA. The TOT PCAs will receive direct funding unless other agreements between TOT PCAs and Lead PCAs request funding to go to the lead PCA. Funding for travel of TOTs coordinators to the DM III and Cardiovascular I kick-off is to be included in PCA budgets.
20. Collaboration with Patient Visit Redesign coaches to provide an introduction of the redesign principles along with additional learning opportunities.

In support of these National Goals, the BPHC plans to:

1. Provide funding in the PCA budget for registration fee and travel support for health center faculty for the "kick-off" learning session for DM III and Cardiovascular I.
2. With IHI, provide updated software registry program that includes both diabetes and cardiovascular data elements, reports, and visit sheets.

In support of these National Goals, Center Disease Control plans to:

1. Support and facilitate partnerships with State diabetes control program and State health department cardiovascular activities with health center teams.
2. With BPHC, IHI and cluster directors, design and implement training for State DCP professionals in care and improvement model.