Module 4: Action — Learning From Activities Underway

Discussing the role of State government in improving diabetes care, Dr. Lawrence Harkless, Chairman of the Texas Diabetes Council, had advice for State leaders interested in diabetes quality improvement. "Poor quality diabetes care is not about bad people, it's about bad systems. In the fifteen minutes a doctor has with a patient, he/she will address the most pressing health concerns. So many of these patients have multiple conditions that create competing priorities for doctors." "Until research provides a cure for diabetes, constant efforts to increase awareness, knowledge and skills — in our health sciences schools, our private and community health centers, our schools and our local and State government — are crucial to our success in controlling this destructive disease," he added. "The economic costs from lost productivity, the health care costs of life-threatening complications, and the personal costs of limited fulfillment – these are costs our State can ill afford to pay." — Dr. Lawrence Harkless, Chairman of the Texas Diabetes Council, and Professor, Department of Orthopedic Surgery, and Louis Bogey Professor of Podiatric Medicine and Surgery, University of Texas Health Sciences, San Antonio, Texas

Module Overview: Selected Public/Private Quality Improvement Initiatives Selected Federal Programs and Resources for Diabetes Care Quality Improvement State Approaches to Diabetes Care Quality Improvement Partnership/Planning Program Development Dissemination Profiles of Selected Best Practice States Selected Local Quality Improvement Efforts Summary and Synthesis List of Associated Appendixes for Use With This Module Key Ideas in Module 4: There are a variety of quality improvement initiatives at the national, State, and local levels that are sparking change in health systems across the Nation. States can use this module for examples and resources for action and for assessing the scope of current diabetes quality improvement efforts in a State. No comparative evaluation of State-level diabetes quality improvement programs has been conducted; however, an evidence-based systematic review of clinical efforts has found provider education, disease management and use of multiple interventions most effective in improving diabetes care.

In Module 1: Background, readers had the opportunity to learn about diabetes, its consequences in terms of cost and its toll on human life, and the need for quality improvement in health care, particularly as it relates to diabetes. Module 2: Data introduced readers to data from the NHQR and how these data can be useful to States. Module 3: Information demonstrated how State leaders could use data to make accurate comparisons and assessments of diabetes care quality in their States. This module will examine various models of quality improvement, ranging from private efforts, not directly related to government, to Federal, State, and local government initiatives.

Within health care, many organizations and individuals play a role in efforts to improve quality. Rather than reinvent the wheel, State leaders have the opportunity to learn and draw lessons from initiatives that are ongoing at both the national and State levels in both the public and private arenas. These initiatives also have publications, guidelines, and other resources that can assist the development of new initiatives. Listed below are selected programs that are central to States and their ongoing diabetes quality improvement efforts. Appendix G gives a more extensive listing of various diabetes quality improvement efforts involving national non-governmental organizations and Federal agencies with Internet links for more information for State leaders.

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Selected Public/Private Quality Improvement Initiatives

There are a wide range of public and private quality improvement initiatives active at different stages of quality improvement. Although the components of quality improvement are numerous, the examples given below illustrate the action at stages most important for State leaders, including the collection of measurement data and the implementation of quality improvement programs. Some organizations focus on one stage of quality improvement while many play a part at all stages. This list is by no means exhaustive, but it provides examples of how national organizations and partnerships are related to State efforts. These strategies are being widely implemented and fine tuned for various populations and organizations.

National Diabetes Quality Improvement Alliance

One of the most important advances in quality improvement is the development of the consensus-based measures to assess health care quality. Organized by leading diabetes stakeholder groups in 1998, the Diabetes Quality Improvement Project (DQIP) was a voluntary coalition of public and private organizations that have cooperated to develop a national set of diabetes-specific performance and outcome measures. Comprised of the American Diabetes Association, the Centers for Medicare & Medicaid Services (CMS), the Foundation for Accountability, the National Committee for Quality Assurance, the American Academy of Family Physicians, the American College of Physicians, and the Department of Veterans Affairs, DQIP was the first successful collaboration to develop a single set of performance measures to determine the appropriateness and effectiveness of diabetes care. The data collected included measures for HbA1c, blood pressure, lipid profiles, eye and foot exams, and smoking cessation counseling, among others.

In 2001, the DQIP partners joined other leading organizations, including the American Medical Association and the Joint Commission on Accreditation of Healthcare Organizations, to form the National Diabetes Quality Improvement Alliance (NDQIA). The Alliance agreed to work on developing one national performance measurement set for diabetes accepted by all major stakeholders. In October 2002, the newly formed Alliance developed national, uniform consensus standards from all parties – purchaser, provider, and consumer groups. The NHQR includes a subset of these measures for which national data exist. Some States have used the DQIP and NDQIA measures as the basis for developing local diabetes guidelines and reporting. Further information on the Alliance and its national measures is available at http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?doc_id=4065.

The Chronic Care Model

One model of quality improvement particularly applicable to diabetes care quality in the clinical setting is the Chronic Care Model. Dr. Edward Wagner and his team at Group Health Cooperative in Seattle, with support from the Robert Wood Johnson Foundation, developed the Chronic Care Model. The U.S. health care system is oriented more toward care for acute episodes of disease rather than prevention and management of chronic conditions. Thus, the Chronic Care Model emphasizes a collaborative approach among health care teams to develop new and better clinical procedures and systems that support providers and patients in treating and managing chronic illness over time. More information is provided below on involvement of State health departments in Diabetes Collaboratives that use the Chronic Care Model to achieve rapid advancement in diabetes care at community health centers. More information on the Chronic Care Model is available on the Improving Chronic Illness Care (ICIC) Web site at: http://improvingchroniccare.org.

The Six Core Components of the Chronic Care Model Community – Mobilizing all the available community resources to meet the needs of people with chronic illnesses. Health System – Creating organizational cultures, systems and mechanisms that promote safe, high quality care throughout the health care system. Self-Management Support – Empowering and preparing patients to manage their health and navigate the health care system. Delivery System Design – Assuring the delivery of effective, efficient clinical care and self-management support through appropriate design of the delivery system. Decision Support – Promoting appropriate clinical care consistent with scientific evidence and patient preferences. Clinical Information Systems – Organizing patient and population data to facilitate efficient and effective care for people with chronic illnesses. Source: MacColl Institute for Healthcare Innovation, Group Health Cooperative, 2004. The chronic care model: model elements. (ICIC is a national program supported by the Robert Wood Johnson Foundation with direction and technical assistance provided by Group Health Cooperative's MacColl Institute for Healthcare Innovation.)

IHI Breakthrough Series Collaboratives

The Institute for Healthcare Improvement (IHI) created the Breakthrough Series Collaboratives to assist health care organizations with making rapid advances in lowering costs and improving quality for a variety of conditions in a variety of health care settings. A collaborative brings together quality improvement experts and practice teams from many different health care organizations that work together for 6 to 8 months to achieve quality improvement in a specific area. Since 1995 when IHI held the first Collaborative, more than 700 trained teams from over 450 U.S. and Canadian health care organizations have participated in these programs. By capitalizing on the collective wisdom of participating organizations, expert faculty, and improvement advisors, these organizations have dramatically improved outcomes and reduced costs in a variety of areas, including:

• Reduced waste in the form of shorter intensive care unit stays and less waiting time.
• Dramatic reductions in defects such as adverse drug events, long waits for pain medications, and unnecessary hospitalizations for chronic conditions.
• New levels of performance achieved including enhanced control of blood sugar and access to primary care.

IHI combined efforts with the Group Health Cooperative's Improving Chronic Illness Care program to train health care providers and others in using the Chronic Care Model to accomplish real change in the way chronic diseases, including diabetes, are treated and tracked (Institute for Healthcare Improvement, 2002). Hundreds of health care teams around the country are currently using the Breakthrough approach combined with the Chronic Care Model in Health Disparities Collaboratives sponsored by HRSA's Bureau of Primary Health Care. (Health Disparities Collaboratives are discussed in further detail later in this module.) The short-term evaluations of Collaboratives showed improvements in blood sugar control for diabetes patients; dramatic increase in followup for patients with depression; decreased rates of blood pressure among patients with cardiovascular disease; success in providing asthmatic patients with daily preventive medicines; and decreasing health care costs even while increasing the number of patient visits (Wagner, Austin, Davis, et al., 2001). More information about IHI, its Breakthrough Series, and diabetes programs can be found on the following Web sites:

• Breakthrough Collaboratives general information: http://www.ihi.org/IHI/Topics/Improvement/SpreadingChanges/Literature/
  TheBreakthroughSeriesIHIsCollaborativeModelforAchievingBreakthroughImprovement.htm
• Improving care for people with chronic conditions — diabetes: http://www.ihi.org/IHI/Topics/ChronicConditions/Diabetes/HowToImprove/
• Report from the Health Disparities Collaborative on Diabetes: http://www.healthdisparities.net/Diabetes_Apr2002.pdf (Report no longer accessible).

Other Strategies

Self-Management Programs

Diabetes is one chronic condition whose treatment and outcomes are heavily dependent on how well the patient monitors and manages the disease outside the health care setting. An important approach to quality improvement for diabetes is improving patient self-management. Self-management programs emphasize and focus on patient education and behavior modification. Health care professionals work with patients to build their confidence in managing their own disease, in working within the health care system and the community to have their needs met, and in managing the emotional effects of their illness. Patients are informed about their disease and trained using evidence-based information in how they should manage their condition. A variety of educational tools are used to assist the patient (for example, classes, Internet information, and toll-free hotlines). There are national standards for diabetes self-management and patient education. Because of the critical role of patient self-management in diabetes care, some purchasers are beginning to provide reimbursement for certified diabetes educators to interact with diabetes patients.

One AHRQ-sponsored study conducted by Stanford University researchers showed that 2 years after participating in a self-management program, study participants showed reductions in health distress, made fewer visits to the doctor's office and emergency room, had not experienced any further increases in disability, and had increased self-efficacy (Lorig, Ritter, Stewart, et al., 2001). More information on the Chronic Disease Self-management Program at Stanford University is available at: http://patienteducation.stanford.edu/programs/.

Disease Management Programs

Another model for quality improvement that is capturing attention nationwide is disease management. Disease management is a term that refers to a variety of programs and interventions that seek to:

• Identify patients with a particular chronic condition or set of conditions.
• Establish a coordinated system of interventions and information-sharing for enrolled patients and their providers.
• Encourage doctors and other health care providers to use evidence-based practice guidelines to treat chronic illnesses.
• Educate and train patients in self-management so that they avoid disease complications.
• Monitor interventions and outcomes over time to evaluate the effectiveness of the disease management program.

Disease management has grown rapidly over the past five years and is now used widely by employer-sponsored health plans to manage costs and improve clinical care for many chronic conditions, including diabetes. More recently, State Medicaid programs and Medicare also have begun to use disease management for their populations. Initial assessments from State Medicaid disease management programs are promising in terms of cost control and quality improvement (Brown and Matthews, 2003; Wagner, Austin, Davis, et al., 2001; AAHP/HIAA, 2003). Table 4.1 below lists Medicaid diabetes disease management efforts that are underway. More information on disease management programs in general is available from the Disease Management Association of America's Web site at http://www.dmaa.org. Further information on diabetes disease management programs is available at the Council of State Governments' (CSG) Web site at http://www.healthystates.csg.org/.

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Selected Federal Programs and Resources for Diabetes Care Quality Improvement

In addition to public/private quality improvement efforts, State diabetes efforts are also linked with Federal programs. There are a variety of programs at the Federal level that address diabetes and quality improvement; some of these are partnering with States, and others have useful resources for State efforts.

CDC's Diabetes Prevention and Control Program.

The Centers for Disease Control and Prevention currently helps to fund the Diabetes Prevention and Control Program (DPCP) in every State. The DPCP model began as a small number of demonstration projects in the late 1970s. In response to the growing burden of diabetes in the United States, the program has evolved into a nationwide, joint State-Federal effort with the CDC spending $20 million annually throughout the 50 States, the District of Columbia, and 8 U.S. territories and island jurisdictions. These programs and the people who staff them are rich information resources on diabetes. (Go to http://www.cdc.gov/diabetes/states/index.htm for links to each State DPCP.)

The CDC's DPCP has developed two types of programs: capacity building and basic implementation. Twenty-six States currently have capacity building grants with an average award of $270,000 to:

• Develop initial expertise in diabetes control.
• Provide a focal point for diabetes control.
• Establish systems to define the scope of the diabetes problem.
• Identify gaps in diabetes care, for both patient access and quality-of-care issues.
• Develop and evaluate limited intervention projects.
• Identify external supporters for diabetes control activities.

DPCP's basic implementation program awards an average of $725,000 to State health departments. Twenty-four States currently have basic implementation grants. The implementation grants are to:

• Build on expertise in program, science, and policy areas to control and prevent diabetes.
• Coordinate statewide diabetes control and prevention.
• Expand systems to define and analyze the scope of the diabetes problem.
• Improve access to diabetes care for all people and raise the quality of that care.
• Use statewide public health projects to reduce diabetes-related problems.
• Inform, educate, and empower external supporters to control and prevent diabetes.

To qualify for CDC funds, State governments are required to provide matching support through State funds or in-kind commitments of personnel or other resources. The amount of State funding varies. Some States provide a significant level of their own funding for diabetes efforts, surpassing CDC funding by two or three times. Texas, for example, appropriated more than $6 million in State funding for diabetes in fiscal year 2003-2004. Other States provide more modest support or no additional support. In addition, money is often provided through private grants. States with higher incidence of diabetes also do not necessarily spend more on their diabetes prevention and control programs. CDC aims to assist State health departments in developing programs to address the disease; CDC funding amounts to approximately $1.27 per American with diabetes (go to Appendix H for a breakdown of CDC and State DPCP funding for all 50 States).

In 1999, the CDC required each State to establish measurement and evaluation procedures to track and promote program success. DPCP uses a "model of influence" approach. As such, the DPCP acts as a mechanism for improving diabetes care through strategic partnering and programmatic interventions. The purpose is to ultimately affect broad change in the health system and the health of the community. The evaluation and accountability requirements are meant to stimulate such activity on the part of the DPCP (Safran, Mukhtar, Murphy, 2003). The evaluation framework of this policy shift is detailed in the discussion on evaluation in Module 5: Improvement.

Diabetes Detection Initiative and Steps to a HealthierUS

Under the leadership of Secretary Tommy G. Thompson, the U.S. Department of Health and Human Services has developed a new initiative, the "Diabetes Detection Initiative: Finding the Undiagnosed." More than 5 million of the 18.2 million people with diabetes in the United States do not know they have the disease. The Diabetes Detection Initiative (DDI) is a community-based effort to identify individuals with type 2 diabetes who have not been diagnosed. The DDI is designed to raise awareness of diabetes risk factors, increase blood testing of individuals at risk for diabetes, and increase diagnosis and treatment for those people who do not know they have the condition.

Ten communities around the Nation with high risk populations are serving as DDI pilot sites, including Oakland, California; Wichita and Sedgwick County, Kansas; Springfield/Holyoke, Massachusetts; Flint, Michigan; East Harlem, New York, Choctaw Nation, Oklahoma; Orangeburg County, South Carolina; Seattle, Washington; Fayette and Greenbrier Counties, West Virginia; and Wind River Indian Reservation, Wyoming. Future plans calls for the DDI to expand to other locations across the country. The Diabetes Detection Initiative is aligned with other Federal health initiatives, including the Secretary's Steps to a HealthierUS and the President's HealthierUS programs, which are aimed at encouraging physical activity, improved nutrition, and a more prevention-oriented society. More information on the DDI is available at http://www.ndep.nih.gov/ddi; additional information on Steps to a HealthierUS is available at http://www.healthierus.gov/steps/index.html.

HRSA's Health Disparities Collaboratives

HRSA's Bureau of Primary Heath Care (BPHC) and the CDC's Diabetes Prevention and Control Program sponsor Health Disparities Collaboratives, a unique partnership with community health centers (CHCs) across the country aimed at improving chronic illness care for underserved and minority communities. CHCs are the key safety net providers for low-income, uninsured patients throughout the country. The low-income and ethnically and racially diverse populations at community health centers have an increased risk of complications from chronic illness (NACHC, 2003). In an ambitious program to reduce health disparities, HRSA began the first Diabetes Collaborative in 1999 with 85 CHCs. The CHCs developed registries and enrolled 16,000 people with diabetes in the collaboratives. In 2000, another 120 health centers participated in a second Diabetes Collaborative.

The Health Disparities Collaboratives incorporate the change model created by the IHI Breakthrough Series and the Chronic Care Model for diabetes care improvement. This program has allowed CHCs to participate in team training to apply best practice models of care for chronic disease. The population-based model of care relies on identifying which patients have an illness and ensuring that they receive evidence-based care. The model helps patients to participate and manage their conditions. Over the course of the 1-year collaborative, the CHC teams participate in learning sessions and set goals, such as data collection on certain outcomes (for example, blood tests). Then they develop, test, and implement evidence-based strategies for a specific clinical area (for example, diabetes) and for a specific community. Between meetings, CHC teams focus on implementing goals and measuring changes in their health centers. The team collects data to measure the impact of the changes and additional learning opportunities allow teams to improve processes over time. The teams share information and learn from national experts and each other through a Listserv, regular site visits, monthly progress reports, and conference calls. Results indicate the rate of HbA1c testing for people with diabetes increased significantly at the participating centers over the first year (Health Disparities Collaborative, 2004).

Additional information on the Bureau of Primary Care and the Health Disparities Collaboratives is available at http://www.healthdisparities.net/.

National Diabetes Education Program

The National Diabetes Education Program (NDEP) is a national collaboration sponsored jointly by the National Institutes of Health (NIH) and the CDC. The NDEP includes over 200 partners at all levels of government and society. Many State DPCPs use NDEP materials and partner on NDEP initiatives. The goal of the NDEP program is to improve prevention and treatment of diabetes, thereby reducing illness and death from this disease. Because so many of the complications from diabetes are preventable, the NDEP seeks to help educate the public about diabetes, promote better patient self-management, improve the quality of care for diabetes, address health policies that may improve quality and access to care, and reduce disparities among racial and ethnic populations that are disproportionately affected by diabetes. A variety of resources on diabetes quality of care improvement as well as education and awareness campaigns and other resources are available at the NDEP Web site at http://ndep.nih.gov. Another part of the NDEP is a Web site devoted to improving diabetes care at http://www.betterdiabetescare.nih.gov/MAINintroduction.htm. The site has information, resources and tools for providers, educators, and organizations on how to participate in and advance quality improvement in diabetes care.

CMS' Quality Improvement Organizations

Under Titles 11 and 18 of the Social Security Act, Quality Improvement Organizations (QIOs) are designated as the guardians of quality, cost-effective care for both Medicare and Medicaid. The 37 QIOs in the United States, also known as peer review organizations, are non-profit organizations that operate under the direction of the Centers for Medicare & Medicaid Services. QIOs are responsible for using medical reviews, data collection and analysis, and other functions authorized by CMS as a means to achieve national, State, and local quality improvement goals. QIOs are vital partners in CMS' Health Care Quality Improvement Program due to their collaborative relationships with local networks of hospitals and providers. QIOs have been involved in several State and local quality improvement projects related to diabetes. Qualis, a QIO in Washington State, was a partner with the Washington State Department of Health and the Improving Chronic Illness Care program of the Robert Wood Johnson Foundation in the Washington State Diabetes Collaborative. Missouri's QIO, MissouriPRO, participated in the HRSA Health Disparities Collaborative for diabetes in community health centers in the State. North Dakota's QIO has assisted clinics with implementing diabetes flow sheets, increasing preventive care and screening and establishing a diabetes care tracking system that generates reminders for routine diabetes checks. General information on the role of QIOs is available at http://www.cms.hhs.gov/QualityImprovementOrgs/01_Overview.asp. Specific information on QIO diabetes quality improvement initiatives is available at http://medqic.org/dcs/ContentServer?cid=1097592510511&pagename=Medqic%2FMQLiterature%2FLiteratureTemplate&c=MQLiterature. Examples of QIO initiatives in various States are available on the American Health Quality Association Web site at http://www.ahqa.org/pub/quality/161_689_2974.cfm.

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