| Health system change | Resources/support | |
|---|---|---|
| National | State/coalition | |
| Health care organization: Create a culture, organization and mechanisms that promote safe, high quality care. | ||
| Assist senior leadership in determining the value of improving chronic care | Business Case Studies: Preparing for an Executive review of Improvement Projects: |
|
| Make improving chronic care part of the health center's vision, mission, goals, and performance improvement and business plans. | Leaders' Guide—Developing the Business Case
for Planned Care: Changing Practice, Changing Lives: The Health Disparities Collaboratives,
Training and Promotional Videos: |
|
| Orient new clinicians to the collaborative | Asthma Health Disparities Collaborative Training
Manual for Chronic Conditions: Texas Association of Community Health Centers Distance Learning Tool with training modules for the Collaborative. These courses may be used by individuals to become oriented to the Care Model, learn how to apply the model to any of the targeted chronic illnesses, or simply as a Collaborative training tool and resource. To access, go to http://classroom.tachc.org and select "Request an Account." |
|
| Embed measurement and monitoring in work flow. | Senior Leader Monthly Report Form: Example
of Senior Leader Report: |
|
| Assess organizational and individual understanding of culturally and linguistically effective care. | Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile: http://www.hrsa.gov/culturalcompetence/indicators/default.htm#conclusion Andrulis
D. Cultural Competence Self-Assessment Protocol for Community
Health Centers: |
|
| Financial or organizational incentives to participate in quality improvement | Pay for Performance Incentive Programs in Healthcare
2003: http://www.leapfroggroup.org/media/file/Leapfrog-Pay_for_Performance_Briefing.pdf |
|
| Self-management support: Empower and prepare patients to manage their health and health care. | ||
| Consumer/patient asthma education | National Asthma Education and Prevention
Program: Medline Plus Asthma Tutorial: National
Institute of Allergy and Infectious Diseases, How to
create a dust free bedroom: Starlight,
Starbright Children's Foundation, Quest for the
Code®: Environmental Protection
Agency: |
Michigan Asthma Resource Kit, Patient Section: |
Emphasize and educate the patient and family about their role in the management of asthma:
|
American Lung Association Open
Airways for Schools, The Group Health Center for Health Studies (CHS) Readability Toolkit (2006) helps to create materials that patients and health care consumers can understand: http://www.improvingchroniccare.org/downloads/ readabilitytoolkit_seconded_092606.pdf Health Disparities Collaboratives Web site has several sources on health literacy and limited literacy: http://www.healthdisparities.net/hdc/hdcsearch/isysconcept/ Special Populations—Considerations/Health Literacy—Limited Literacy/ Office
of Minority Health Web site has culturally appropriate patient education
materials: |
|
| Use effective self-management support strategies that include assessment, goal setting, action planning, problem solving, and followup. | Assessment:
Goal Setting:
Shared Care Plan: Asthma Peak Flow Diary: Supporting Self Management With the 5 A's: |
Goal Setting:
Asthma Peak Flow:
|
| Delivery system design: Assure the delivery of effective, efficient clinical care and self-management support. | ||
| Use the registry data to review care and plan visits [see clinical information system] | Whitney M Young Jr. Health Center, Albany,
NY. Integrating Your Asthma Registry in Daily Care: |
|
| Define roles and distribute tasks among team members to optimize staff efficiency and promote a multi-disciplinary care system. | Huddle List: Staff Suggestions for Huddle Contributions: |
|
Use planned visits to support evidence-based care:
|
Asthma Visit Flow Sheet (condensed): Asthma Clinical Visit Flow Sheet: Group Visit Starter Kit: Planning Group Visits for High Risk Patients, American Academy of Family
Physicians: |
|
Make designated staff responsible for and ensure regular followup
|
Asthma coalitions link to volunteers and others who can assist with followup. | |
| Provide or link to clinical case management services. | Coalitions provide or locate asthma clinical case management services in community | |
Provide or link to lay-educator led education. |
MI Partners on the PATH (Chronic Disease
Self-Management Program) Support Groups: http://www.aafa.org/esg_results.cfm?state=MI |
|
| Create a system to identify and vaccinate all patients with asthma for influenza. | FQHCs use Michigan Childhood Immunization Registry to track influenza immunization for children with asthma. | |
| Linkage to emergency department for followup from ED visits. | FLARE: Emergency Department Discharge
Asthma Instructions: http://www.getasthmahelp.org/FLARE.asp |
|
| Provide care that patients understand and that fits their culture. | Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile: http://www.hrsa.gov/culturalcompetence/indicators/default.htm#conclusion Andrulis D. Cultural Competence Self-Assessment Protocol
for Community Health Centers: |
|
| Decision support: Promote clinical care that is consistent with scientific evidence and patient preferences. | ||
| Embed evidence-based guidelines into daily clinical practice. | National Asthma Education and Prevention
Program Expert Panel Report 2: Guidelines for the Diagnosis and Management
of Asthma: National Guideline Clearinghouse™: Shenandoah Valley Medical System, Inc. Asthma Progress Note: |
Michigan Asthma Resource Kit, Professional
Section: Michigan Quality Improvement Consortium Asthma Guidelines for Primary
Care: |
Referral to specialist to integrate specialist expertise and primary care.
|
||
| Provide skill oriented interactive training programs for all staff. | Provider Training in Choices and Change: One Minute Asthma Training: Texas Association of Community Health Centers Distance Learning Tool with training modules for the Collaborative. To access, go to: |
Coalition provides, obtain resources, or otherwise assists with provider education |
Share guidelines and information with patients:
|
One Minute Asthma, 7th Edition: |
|
| Develop refill protocol to identify overuse of beta antagonists. | ||
| Clinical Information systems: Organize patient and population data to facilitate efficient and effective care. | ||
| Patient registry to identify population and to facilitate individual patient care planning. | Midwest Clinician Network, Patient Electronic
Care System (PECS) registry: |
|
| Develop processes for use of the registry, including designating personnel or volunteers to enter, assure data integrity, and maintain the registry. | Using Monthly Health Center Data: Senior Leader Monthly Report Form: |
|
| Use the registry to generate reminders and care planning tools for patients and providers | Midwest Clinician Network, Patient Electronic
Care System (PECS) registry: http://www.midwestclinicians.org/health/reg_report.htm [based at the Michigan Primary Care Association] |
|
| Conduct monthly identification of poorly controlled asthma via billing data; identify relevant subpopulations for proactive care. | Midwest Clinician Network, Patient Electronic
Care System (PECS) registry: http://www.midwestclinicians.org/health/reg_report.htm [based at the Michigan Primary Care Association] |
|
| Facilitate individual patient care planning. | Huddle List: |
|
| Data analysis to monitor performance of practice team and care system | Using Monthly Health Center Data: |
Midwest Clinician Network, Patient Electronic
Care System (PECS) registry: http://www.midwestclinicians.org/health/reg_report.htm [based at the Michigan Primary Care Association] |
| Community resources and policies: Mobilize community resources to meet patient needs. | ||
Link to community, evidence-based resources:
|
Freedom from Smoking online: |
Power Breathing, Wee Wheezers & Wee
Wheezers At Home, and other programs and services offered by the
Asthma & Allergy Foundation of America, Michigan Chapter: Michigan Tobacco Quit Line: AIM Community Web site, including links to asthma coalitions: American Lung Association of Michigan: Asthma coalitions to provide referral and community information, as requested by the FQHC. |
| Form partnerships with community organizations to support and develop programs that meet gaps. | "Never Judge a Book by Its Cover, and
Other Important Lessons About Asthma" school packets: http://www.getasthmahelp.org/intro_schools.asp |
|
| Form partnerships with community organizations to obtain donations/resources for educational materials, provider education, medications, equipment, and other necessary supplies/materials. | Pharmaceutical companies |
Asthma coalition to provide links to possible pharmaceutical, foundation, and community partners to assist with providing educational materials, equipment, and other supplies. |
| Advocate for policies to improve care. | Involve FQHC in MAAC and its subcommittees. | |
Note: National and State/coalition resources are listed in all areas in which they are appropriate.
* Examples of importance and confidence rulers are presented in Appendix D.