Chapter 2. Project Description

Goal

This improvement initiative aimed to assist community health centers in redesigning their systems to increase patient self-management through goal setting and patient activation.

Tools

Action Plan

All clinics were to implement the Action Plan,² a tool used by the Health Resources and Services Administration's (HRSA) Health Disparities Collaboratives (PDF File, 33 KB; Text Version). This one-page tool, which is completed by the patient and clinician together:

• Focuses on patient goal setting with simple pictures to represent six activities.
• Encourages patients to choose an activity that will help them improve their health.
• Includes an activation measure for patients to rate their confidence level in achieving their goal.

This tool was produced in triplicate by carbon copy, with one copy for the patient, one copy retained by the health center within the patient's record, and one copy sent to Delmarva for data entry and analysis. Delmarva analyzed the data for:

• The number of patients with Action Plans completed.
• The number of patients that were Hispanics.
• The type of goals most frequently chosen.
• How the type of goals varied by age and gender of patients or discipline of clinic team member.

The Action Plan consisted of three parts.

1. The patients chose one or more of the following activities but were encouraged to focus on one change at a time:
   • Working on something that is bothering them.
   • Staying more physically active.
   • Taking medications.
   • Improving food choices.
   • Reducing stress.
   • Cutting down on smoking.
2. The patients filled in brief information about the selected activity:
   • What the chosen activity was.
   • How much they would do the activity.
   • When they would do the activity.
   • How often they would do the activity.
3. The patients indicated how confident they were in their ability to accomplish the Action Plan on a ladder scale of 0 to 10, with 0 representing "not sure at all" and 10 representing "very sure."

Activation Assessment Tool

Measuring patient activation for change can help providers tailor their counseling and care and assess how well they are supporting their patients in self-management.

The Activation Assessment Tool³ is the Stanford Patient Education Research Center's Spanish Chronic Disease Self-Efficacy Scale, a four-item questionnaire (PDF File, 50 KB; PDF Help) that was optional for clinics to use in this intervention. This tool, which is completed by health center clinicians with patients during the patient visit:

• Measures how confident patients are in managing their own care and understanding their treatment.
• Uses a 10-point scale to evaluate how confident the patient is in managing his or her disease, with 1 representing "not at all confident" and 10 representing "totally confident."
• Assesses the patient's confidence in avoiding the interference of the following with activities he or she wants to perform:
  • Tiredness or fatigue related to the disease.
  • Pain or symptoms related to the disease.
  • His or her emotional condition related to the disease.
  • Other symptoms or health problems.
• Assesses overall self-efficacy when the scores of the four areas of patient confidence noted above are averaged.
• Assists the clinician in knowing where additional support and counseling might be needed by the patient.

The Activation Assessment Tool was produced in duplicate by carbon copy, with one copy retained for the patient's record and the other copy batched and sent monthly to Delmarva for analysis. Delmarva determined the number completed, the variation in scores by patient age and gender, and whether clinicians felt the tool was helpful in goal setting.

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Measures for Intervention

One patient clinical outcome measure and four process measures were used to assess the effect of the intervention. All measures focus on patients of providers in the participating clinics.

Outcome Measure

Measuring and comparing HbA1c level. This blood test is used to determine how well diabetes has been controlled in a recent (2- to 3-) month period. Lowering the HbA1c is associated with a reduction in the complications of diabetes. The baseline average HbA1c level for clinic patients with diabetes was compared to the average HbA1c level of the same group in December 2006 after 6 months of the intervention and data collection. With only 6 months for this intervention, a significant change was not anticipated in this outcome measure. The emphasis was on increasing the process measure for goal setting during the intervention period. However, the participants were aware that monitoring should be continued after the intervention period to determine if:

• The average HbA1c of patients with diabetes improved.
• The average HbA1c of patients with diabetes and completed Action Plans improved at a greater rate than the average HbA1c of patients with diabetes without completed Action Plans.
• The average HbA1c of patients with diabetes making progress on their goal on the Action Plan improved at a greater rate than those patients that did not make progress on their goal on the Action Plan.

Process Measures

Rate for goal setting for patients with diabetes. The rate for goal setting was compared at baseline and after 6 months of the intervention.

Number of patients with diabetes with completed Action Plan  x 100
Number of patients with diabetes seen during the intervention

Rate of patients making progress on goals. This measure assessed the rate of patients with diabetes with two or more Action Plans completed during the intervention that made progress on at least one goal between the first and last visit of the intervention.

The number of patients with two or more Action Plans completed that
reported progress on or achievement of one goal between the first and last visit  × 100
Total number of patients with two or more Action Plans completed

Two measures in the original evaluation design were omitted: 1) the utilization rate of the Activation Assessment Tool and 2) the average point change between the first and second Activation Assessment ratings of patients with diabetes. The measures were omitted due to the consensus of the clinics to discontinue use of the Activation Assessment Tool for this intervention.

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Other Data to be Collected

• Total number of Hispanic patients with diabetes of participating providers seen during the intervention.
• Age and gender of patients completing Action Plans.
• Rate of selection for each of six goals on Action Plan.
• Number of goals selected by patients with completed Action Plans.
• Descriptive analysis of clinicians' assessment of the value of the Action Plan and the Activation Assessment Tool in helping them with patient self-management and goal setting.
• Distribution of ratings on four questions of Activation Assessment Tool.
• Participants' assessment of Learning Sessions.
• Clinic staff assessment of intervention.

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Data Collection Challenges

The intervention was designed to decrease the disparities in diabetes in Hispanics. The clinics served a predominately Hispanic population, and over 96 percent of the Action Plans (PDF File, 33 KB) completed were for Hispanic patients. To capture the percentage of Hispanics participating in this intervention, a question was added to the Action Plan relative to whether the patient was Hispanic or not and the clinic team circled either "Si" or "No."

Five health centers had a data collection registry, and expectations were that they would calculate a baseline and a post-intervention goal-setting rate. However, the following challenges were encountered.

• Two of the clinics with a registry were not able to provide a baseline measurement.
  • These clinics had not participated in any initiative or effort to establish goal setting and felt their baseline goal-setting rate would be minimal.
  • One clinic was unable to provide a baseline or post-intervention measurement for goal setting. This clinic used the Action Plan in the diabetes school, did not utilize interactive goal setting (the patient completed the Action Plan after receiving instructions), and did not integrate the Action Plan into the medical record.
• One clinic did not have a chronic disease registry or a baseline measurement for goal setting. This clinic:
  • Had not participated in any goal-setting intervention, and believed its baseline documented goal-setting rate would be minimal.
  • Was unsuccessful in implementing the intervention for a variety of reasons, including dependence on volunteer clinicians and relocation of the clinic during the intervention.

The five clinics with the chronic disease registry had a baseline HbA1c for their patients. A method was designed for the clinic without a registry to track HbA1c levels on the patients with diabetes and a completed Action Plan and to calculate a post-intervention average HbA1c.

To determine if patients were making progress on goals, the clinic team members were to complete a second Action Plan for patients during the followup visit in 3 months. On this Action Plan the clinics were to note whether the patient had made progress on achieving his or her goal. Delmarva was to analyze the Action Plans for age, gender, types of goals most frequently chosen, and the rate of progress made on goals. However, clinics did not complete and submit Action Plans for the second visit. They did not consider the time to complete a second Action Plan valuable. Instead, the clinician used the original Action Plan and updated as follow-up status was discussed with the patient during subsequent visits. This change in approach meant that the percentage of patients with progress toward their goals could not be calculated. Delmarva was able to analyze the data for types of goals selected by different clinics.

Data challenges for quality improvement in these community clinics should not be underestimated. Without a chronic disease registry, data collection requires too many resources for ongoing quality improvement activities. Even with a disease registry, the additional paperwork required of clinic teams is time consuming, interrupts the patient flow, and may be completed on an irregular basis.

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^2. Formarly available at: http://www.healthdisparities.net/hdc/hdcsearch/isysquery/7621461c-f369-4da1-9efc-df59aeae1401/13/doc/. This document is in the public domain.
^3. Available at: http://patienteducation.stanford.edu/research/secdesp.html. This document is in the public domain.

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