Quality Grant Project Abstracts

Box Butte General Hospital, d.b.a. Sandhills Family Center
Alliance, Nebraska

The purpose of the Sandhills Family Center Partnership is to improve patient care and chronic disease outcomes for patients served by Box Butte General Hospital, d.b.a. Sandhills Family Center (hereafter Sandhills Family Center) located in Alliance, Nebraska, through the development, implementation and evaluation of diabetes and cardiovascular quality improvement strategies. This is being accomplished by utilizing the DocSite patient registry system to track and report specific health indicators for patients with diabetes. Cardiovascular diseased patients will be added and implemented using the same format.

Currently, the Sandhills Family Center provides health care services to approximately 1200 patients living in the City of Alliance. Over 100 of these patients have a primary diagnosis of Diabetes Mellitus (DM). Almost 200 of the Center's patients have a primary diagnosis of Cardiovascular Disease (CV). It is important to note that these figures represent 1) a primary diagnosis only and 2) do not include patients who are diagnosed with pre-diabetes and pre-cardiovascular disease. These numbers have the potential to be much higher.

Patients newly diagnosed with DM are referred to the Dietician for training and education. Patients diagnosed with CVD are first encouraged to control their diet. If results are not positive, then medication and a Dietician consult are prescribed.

Patients seeking care at the Sandhills Family Center vary from infants to the elderly, since all providers at the Sandhills Family Center are family practice. Patients served at the center are primarily White, Hispanic or Latino in race. Approximately 15% of the Sandhils Family Center's patients speak Spanish as a primary language. Nearly 1 in every 10 residents in Alliance is of Hispanic or Latino ethnicity. Patients generally have a commercial insurance or are covered by Medicare and Medicaid. Most patients have a high school education, with approximately 35% having some form of higher education.

The city of Alliance, like many rural communities, has an increasing number of patients, many of whom are indigent, and afflicted with obesity and diabetes. Financial and technical assistance from the Small Health Care Provider Quality Improvement Grant Program is assisting the Sandhills Family Center in improving the treatment and care of these patients, affording them a better quality of life and reducing complications from this disease, thereby lowering health care costs for the community as a whole.

Also, having access to the DocSite registry tool that is populated with best practices and quality measures reduces the burden on a limited number of staff and allows them to focus on quality improvement and date collection, and ultimately improve patient care. The DocSite registry system is providing the Sandhills Family Center the opportunity to track and report specific health indicators for patients diagnosed with DM disease and offers the opportunity to track CV disease and the possibility to track other diagnoses and result in improved patient care.

North Sunflower Medical Center/Sunflower Clinic
Ruleville, Mississippi

The caring clinical team at North Sunflower Medical Center has been frustrated in its efforts to ensure that high quality care is delivered to people living with DM or CVD by the outdated reporting records still in use at the hospital. While the health center has experienced tremendous growth and success over the past few years, its reporting methods remain paper-based, including its quality improvement program. It is virtually impossible to collect and report summary data as the methods would involve opening and searching each medical record.

The Small Health Care Provide Quality Improvement Grant will be used primarily to establish an electronic patient registry system to facilitate quality improvement activities.

North Sunflower Medical Center’s primary service area is Sunflower County, a population at increased risk for chronic health problems such as diabetes mellitus and cardiovascular disease. Educational achievement and income levels of Sunflower county residents are significantly lower that state averages. Eighty-five percent of the hospital’s case mix is patients covered by Medicare and Medicaid. For example, only 59.3 percent of county residents aged 25 years and over are high school graduates and only 12 percent have earned bachelor’s degrees or higher compared to 72.3 percent and 16.9 percent, respectively, for Mississippi residents. Median household ($24,970) and per capita incomes ($11,365) of Sunflower county residents also fall lower than state averages of $31,330 (household) and $15,853 (per capita) (United States Census Bureau, 2004). Fully 30 percent of Sunflower County residents live below the poverty level compared to the state rate of 19.9 percent. Based on the number and variety of health care providers and the demographics of county residents, the Health Resources and Services Administration (HRSA) has designated Sunflower County as a Health Professional Shortage Area, a Mental Health Profession Shortage Area, and a Medically Underserved Area. Ominously, particularly considered its HPSA and MUA designations, this region is known as the “pathology bowl” of the nation.

North Sunflower Medical Center has a working population of DM patients that are currently being monitored. As the second year of the grant unfolds, additional DM patients and CVD patients will be added.

Benson Area Medical Center
Benson, North Carolina

Benson Area Medical Center is a community-owned nonprofit rural health center located in Benson, North Carolina. We currently serve nearly 10,000 patients in our rural catchment area including portions of Johnston, Harnett, and Sampson counties. For over 28 years our practice has been committed to providing care to all members of our community and we serve disproportionate numbers of citizens on Medicare, Medicaid, or with no health insurance. A high local poverty rate and a high percentage of uninsured patients in our area make providing health care here a challenge.

Diabetes and cardiovascular disease are significant health problems in our community. Of the 9,985 patients currently registered with our practice, at least 1,062 already carry a diagnosis of diabetes. Approximately 22% of our 26,000 annual patient encounters are for diabetes care. We have also had 990 follow-up visits for cardiovascular disease in our patient population within the last calendar year.

Optimal control of diabetes and prevention of associated complications can be achieved by carefully managing clinical measures including hemoglobin A1C levels, lipid levels, and blood pressure. To prevent heart attacks and strokes it is important to monitor patients with cardiovascular disease for appropriate blood pressure management, lipid management, smoking status and use of lifesaving medications. We believe that we can help our patients with diabetes and cardiovascular disease remain healthier by utilizing a computerized system for monitoring key performance measures in a systematic way that will allow us to track the success of current and future quality improvement efforts.

Our commitment to caring for underinsured and uninsured members of our community places us in a financial situation that precludes the independent purchase of such a system. Thus last year we applied for and received the Small Health Care Provider Quality Improvement Grant to establish an electronic registry system and to initiate a formal ongoing quality improvement program.

Initial grant monies have allowed us to purchase needed equipment and to contract with the DocSite patient registry system. We have been tracking key performance measures for one provider’s patients with diabetes in our practice and have initiated interventions aimed at improving care for these patients. For the remaining initial grant period, we plan to extend the registry to all of our diabetic patients. We will then be able to follow quality improvement interventions related to diabetes care across our entire population of diabetics.

In the next year, we plan to add cardiovascular disease to our patient registry. We will then be able to track key performance measures for patients with both diabetes and cardiovascular disease. Based on information from the diabetic registry patients, we have already begun efforts to increase compliance with recommended yearly foot and eye examinations. This fall we are planning special outreach programs to improve vaccination rates for influenza and pneumococcal pneumonia in our patients with diabetes and heart disease. These and other similar interventions will improve the care our patients receive. By monitoring the results of these interventions through our patient registry system, we can continue to make changes which will lead to better health outcomes for at risk members of our community. We also hope that we can serve as a model for optimal chronic disease management.

The Kingston Hospital
Margaretville, New York

The Kingston Hospital (TKH) is a 160-bed community hospital located in Kingston, New York, a small city that serves as a hub for a wide, rural area including the Catskill Mountains. Margaretville Memorial Hospital (MMH) provides Critical Access medical care, a 24/7 emergency capability, a swing bed unit, two Family Health Centers providing outpatient primary care, outpatient diagnostic testing services, a local ambulance service and an 82-bed skilled nursing facility. In addition, our sister hospital, TKH, arranges for specialists to provide scheduled office hours on the MMH campus in Cardiology, Gastroenterology, Podiatry, Orthopedics and General Surgery. TKH provides MMH with emergency referral backup and 24/7 radiologist services including the installation this year of the PACS system allowing the radiologists located in Kingston to read digital images taken at MMH immediately.

TKH is a non-sectarian, not-for-profit institution whose sole reason for existence is to serve the health care needs of all people in our community. We accomplish this through dedicated, competent staff providing accessible, patient-focused care guided by a commitment to continuous improvement.

MMH is a rural community health care provider within the Kingston Regional Health Care System. MMH provides a continuum of care to persons in Delaware, Greene, Ulster and Schoharie Counties. We provide excellence in personalized family health services through our primary care centers, acute care hospital, emergency care, wellness programs, and long term care services. For over 70 years MMH has been and will continue to be an organization which contributes to the economic, social, and educational well being of the region.

TKH is requesting support to use Kingston Regional Health Care System (KRHCS) corporate and TKH experienced staff time to develop the infrastructure required for a performance improvement project at MMH involving their staff in the project. With appropriate funding, Margaretville Memorial Hospital will be able to continue implementing a Chronic Care Model health system focusing on prevention and management of chronic care diseases such as Diabetes and Cardiovascular Disease. Funds will continue to be used to enhance educational opportunities and self-management capabilities for patients in our area living with these diseases.

Yoakum Community Hospital
Yoakum, Texas

Yoakum Community Hospital has implemented an enhanced chronic disease management system designed to improve health outcomes for its patients with diabetes mellitus and cardiovascular disease. The hospital utilizes a patient registry system to track health indicators for patients with both diseases. In accordance with suggestions from the Institute of Medicine’s (IOM) reports (To Err is Human and Crossing the Quality Chasm), the patient registry system is an innovative means of improving the delivery of care and reducing medical errors through preventative health care measures. Health indicators include blood sugar, HbA1c levels and frequency of testing, blood pressure, and LDL cholesterol, as well as self managed goals such as exercise and weight management. Now in the second year of the program, cardiovascular health indicators will be monitored, including prescriptions for statin drugs, ACE inhibitors, ARB medications, aspirin, and frequency of microalbuminuria screening. These health indicators will continue to be applied to nationally accepted performance measures designed to assess the program’s efficacy in reducing risk factors associated with these diseases. By meeting these performance measures, it is anticipated that long term morbidity will be reduced.

Many of the IOM’s rules for redesign are integral to the health registry system Yoakum Community Hospital has implemented. Furthermore, based on American Diabetes Association recommendations, Yoakum Community Hospital has provided a team of health care providers that collaborate directly with the patient to provide education and to determine individually appropriate goals. A certified dietician helps set goals for diet, exercise, and weight management. A nurse evaluates and advises on techniques for self-administered insulin and blood sugar testing. A collaborating podiatrist and ophthalmologist evaluate at-risk patients as well—this collaboration includes the patient, who assumes an active role in his/her own care to design a personalized action plan. Follow-up appointments and quarterly visits for tests are used to track progress toward meeting identified performance measures.

Recommendations are reported to all patients’ primary care physicians, inviting their participation with Yoakum Community Hospital in its effort to reduce the long-term effects of these chronic diseases for the patient population.

Community Health Programs, Inc.
Great Barrington, Massachusetts

The purpose of the proposed Circle of Care Project is to increase the quality and number of healthy years of life among low income rural residents in Berkshire County, Massachusetts by improving chronic disease management. The Project also aims to contribute to nationwide efforts to eliminate health disparities. The Circle of Care Project will pursue these goals by addressing two urgent, interrelated needs among Berkshire County residents: 1) Diabetes Mellitus (DM) and Cardiovascular Disease (CVD) management; and 2) support structures and systems to enable patients to make behavior changes and comply with medical recommendations.

Healthy eating, medication compliance, stress management, and consistent exercise are challenging in the best of circumstances. For populations facing severe socioeconomic hardships and barriers to accessing medical and social services, a high level of support is absolutely essential. The majority of patients to be targeted through the Circle of Care Project possess the desire and willingness to make lasting behavior changes – the job of Project providers and staff will be to provide steppingstones and consistent, culturally sensitive support to make these changes possible. Funding for the proposed quality improvement activities will allow providers and staff to offer meaningful clinical and support services – many of which are not billable to public or private insurance programs -- that will lead to sustained lifestyle changes and improved health outcomes for patients with Diabetes Mellitus and Cardiovascular Disease.

Through the proposed Community Health Programs (CHP) Circle of Care Project, 75 CHP Health Center (formerly Community Health Center of the Berkshires) patients ages 19-64 who have a diagnosis of Diabetes Mellitus will receive a continuum of services in Year I, as described under the Response Section below. In Year II, those patients needing continued services will remain participants, and 75 patients with a diagnosis of Cardiovascular Disease will be enrolled as participants.

Hospital Service District No. 1-A of the Parish of Richland
Delhi, Louisiana

The applicant, Richland Parish Hospital (RPH), is a Critical Access Hospital with a 501(c)(3) nonprofit designation. RPH is located in Delhi, Louisiana, Richland Parish, in the northeast corner of the state. The hospital is a main provider of health care services in the parish. The SHCPQI Grant Project is administered through the Delhi Rural Health Clinic, which is a provider-based clinic owned and operated by RPH.

Richland Parish has been classified as a Health Professional Shortage Area and a Medically Underserved Population by the Health Resources and Services Administration. There are significant barriers to access to health care in Richland Parish as reflected in the income and poverty demographics, health status indicators, and health disparities.
The focus of the initiative is to enhance and expand existing quality improvement measures, while improving patient care and chronic disease outcomes.
Components of the proposed Patient Care Coordination Quality Improvement Initiative (PCCQII) include:

• Implementation of an Electronic Patient Registry System;
• Formal Assessment of existing Quality Improvement activities for opportunities for enhancement and expansion;
• Development & Implementation of a Patient Care Coordination model to improve the continuum of patient care; and
• Focus on improving patient chronic disease states.

The PCCQII is a technology and data-driven quality assessment and performance improvement program. The program focuses on maximizing outcomes by improving patient safety, quality of care, and patient satisfaction. Quality improvement activities for Diabetes Mellitus will continue to be conducted during the second year of the initiative, along with the added QI activities for Cardiovascular Disease (CVD).

The Project’s target population consists of the rural residents residing in Richland and the surrounding Parishes, including the populations’ uninsured representing 22.6% of the target area population (compared to the state’s uninsured rate of 21.7%).

Community Hospital of Anaconda
Anaconda, Montana

The purpose of this project is two-fold: (1) to formalize a measures-based quality improvement program for chronic disease management and (2) to embed quality measure assessment and linked clinical action within the infrastructure of our community’s healthcare services in a way that allows continuous quality improvement initiatives to become system-driven rather than provider-driven.

Community Hospital of Anaconda is a critical access hospital that provides more than 95% of the community’s local ambulatory care through its family practice, internal medicine, pediatrics, and convenient care clinics. It is located in the town of Anaconda, Deer Lodge County (DLC), Montana. The Economic Research Service of the USDA assigns DLC a RUCC of 7 and notes a population of 9,417 with a median income of < ½ the U.S. average, an unemployment rate of 1.5 times the U.S. average, and with 14.6% of its population below the poverty level. DLC has been designated a Health Professionals Shortage Area (HPSA) by the Department of Health and Human Services.

The project’s target population will include residents of DLC and Granite County with diabetes mellitus (DM) and cardiovascular disease (CVD), including hypertension, coronary artery disease, and congestive heart failure, who receive their care in these two counties.

This project will use an electronic patient registry to capture data regarding selected performance measures pertaining to the evaluation and treatment of patients with these conditions. Analysis and reporting of this data will be used to help direct patient care, according to clinical guidelines designed to improve chronic disease management outcomes.

The impact of this program will be to enhance clinicians’ ability to apply quality of care measures and treatment guidelines that have been shown to improve disease outcomes. This means minimizing the devastating damages of poorly-controlled DM and CVD and bringing improved health care to the population of Deer Lodge and Granite counties.

Charles Cole Memorial Hospital
Coudersport, Pennsylvania

This project is designed to improve patient outcomes by implementing a patient registry program in order to track and record data for patients with chronic diseases, specifically diabetes mellitus and cardiovascular disease. This collection of patient data will enable the physician to effectively educate, treat, and offer the patient better control of their possible life-threatening chronic disease. Furthermore, the physician will report his findings nationally, regionally, and at the PAC (physician advisory committee) which meets on a monthly basis.

Port Allegany Health Center will also create a model of nationally-accepted quality performance measures which will be implemented in the remaining nine Rural Health Care Centers affiliated with Charles Cole Memorial Hospital. The diabetes mellitus performance measures will track and report on specific health indicators such as patients with their HgbA1c =7.0%, their most recent LDL =130 mg/dL and their most recent BMI =25 kg/m². The second year of the project will allow the physician to continue reporting on the diabetes mellitus health indicators and implement indicators for cardiovascular disease such as most recent blood pressure test =140/90 mm Hg, LDL test =130 mg/dL and patients identified as smokers who receive smoking cessation intervention.

Lastly, this project will allow patients diagnosed with DM or CVD to participate in a disease management clinic and also to exercise, with direct supervision, at the Port Wellness Center by offering those patients free wellness passes. The disease management clinic will provide education and support to those patients diagnosed with DM or CVD to enable them to achieve improved outcomes. Offering free wellness passes will be extremely beneficial and crucial in assisting these patients with proper disease management. Currently, patients recommended to exercise are hesitant to exercise at the state-of-the-art wellness center located conveniently onsite at the Port Allegany Health Center because the passes are cost prohibitive and some patients simply do not know how to begin an exercise regimen. This project will also allow us to contribute to the two major Healthy People 2010 goals which are to increase the quality of years of a healthy life and to eliminate our country’s health disparities.

Sierra Vista Hospital
Truth or Consequences, New Mexico

Sierra Vista Rural Health Clinic [formally known as the Sierra Vista Community Health Center] is a department of Sierra Vista Hospital, located in Truth or Consequences, Sierra County, New Mexico. Sierra County is a rural area with a relatively low population density [3.2 person/square mile according to the 2000 census], enjoying a diversity of population. The racial makeup of the county is 87% White, 26.3% Hispanic, with a small percentage of Black or African Americans, Native Americans, Asians, Pacific Islanders, and other races. This does not total 100% because many in our communities identify with two or more races.

Sierra County is a major recreational area in the state of New Mexico, featuring geothermal hot springs, the largest lake in the state, rivers, fishing, State Parks, clean desert air and a year-round temperate climate. These desirable features bring a large snowbird population who come to enjoy the area and bring healthcare needs with them. Many of the anticipated business and residential expansion projects are now underway. Sierra County is growing and we must grow with it.

Of special concern is the incidence of diabetes among area residents. The NM Department of Health Diabetes Prevention & Control Program’s most recently published survey indicates that in Sierra County the rate among adults is 9.1%, just slightly under the statewide rate of 9.2%. With the anticipated population explosion already underway, we at the Rural Health Clinic [RHC] know that means a large increase in the numbers of patients who may be diagnosed or undiagnosed with diabetes and/or cardiovascular disease. The Rural Health Clinic has an urgent need and desire to improve the delivery of health care for all, especially for patients with these diseases that present such high risk for further complications.

The Rural Health Clinic staff has undergone some difficult challenges in this year. Two of our physicians have moved to other areas. However, our Chief of Staff, who is the Physician Champion of this project, is still with us and with the project. We have been able to add a second provider who is Board Certified in Internal Medicine and Pulmonology. We are currently aggressively recruiting a Family Practice provider as well as a mid-level provider. Our patient population includes a very high percentage of patients with diabetes and cardiovascular disease.

It is the goal of our facility to optimize care and minimize complications for all of our patients, especially the patients with chronic health problems. Since the RHC has limited computerization, the staff is without adequate means to organize patient information for providers to use quickly and easily as they develop a plan of care for each patient.

The staff has discussed ways to improve care of our diabetic patients, but without the information provided in a flow sheet, providers are left with the dilemma of sorting through chart information to obtain specific comprehensive information while trying to care for patients in a packed schedule.

In this first year of the project we have established a registry of patients with Diabetes Mellitus [DM] and we use the resulting diabetic flow sheet [called the Visit Planner] to enable the provider to quickly assess the status of each patient regarding lab tests and results, tests completed and/or needed, referrals for ophthalmic and podiatric examinations, and co-morbidities.

The flow sheet information enables the provider to review self-management training provided or needed, patient goals, and enables him/her to engage the patient as partner in the plan for optimum care. The specific markers tracked for evaluation of the DM project are: A1c testing, Blood Pressures, and LDL testing.

In the second year of the project the focus on chronic care will continue, including our diabetic patients and will expand to include patients with cardiovascular disease as well. Every effort will be made to provide evidence-based care for both DM and CVD. The specific markers that will be tracked for CVD patients are Blood Pressures, LDL cholesterol levels, and BMI.

The organized presentation of key information for each of these chronic care groups will enable our providers to assess the needs of each patient quickly and generate an appropriate care plan without spending valuable time thumbing through paper charts to assemble needed information. Utilizing parameters established by Healthy People 2010 will assist us in developing appropriate goals and realistic accomplishment of them.

In this second year, the anticipated addition of a Patient Educator position in the Rural Health Clinic addresses an important need in heath care, providing the needed ongoing patient education needed to enable patients to become proactive in their healthcare and to appropriately manage their chronic conditions.

The establishment of the Visit Planner [registry] and the organization it provides has already proven its worth, enabling accurate screening, intervention and ongoing reassessment of stated parameters. The focus of this project and the population data provided has impacted our entire practice resulting in aggressive patient screening for diabetes or the conditions which indicate the patients would benefit from preventive care and education.

Provision of this tool is essential for our clinic developing an ongoing program by facilitating not only compilation of this data, but also interpretation of that data into improved outcomes of care for these populations.

Sustaining this project after the conclusion of the grant funding is built into this proposal with Sierra Vista Hospital providing 50% support of the two additional key positions for this year, and anticipating the continuation of this model beyond with full support.

Mountain States Health Alliance
Johnson City, Tennessee

Johnson County, Tennessee, a federally designated Health Professional Shortage Area (HPSA), is a geographically isolated and economically disadvantaged rural county with an urgent need for better health care. Improving the quality of the existing health care services through quality improvement measures targeting diabetes mellitus (DM) and in the second year of operations, cardiovascular disease (CVD), will help to prevent the costly and damaging effects of these health problems.

Discontinuity of care for patients with these chronic diseases leads to disastrous long-term results. An analysis of DM and CVD mortality in Northeast Tennessee has found mortality rates in excess of national rates. Prevalent cultural and lifestyle factors (such as high-fat diet and smoking) have contributed to higher than average rates of respiratory diseases, cancer, diabetes, and major cardiovascular diseases. In 2002, DM was listed as the cause of death for 37 people in Johnson County, leading to an effective rate of 203 per 100,000. This far exceeds the U.S. average of 75 and the goal of 45 per 100,000 listed in Healthy People 2010. For CVD, the numbers are even more astounding. Among residents 45-64 years of age, the morbidity rate from diseases of the heart was 254.9 per 100,000. For residents over 65 years of age, this rate was 1,209.3 per 100,000 (Community Diagnosis, 1999). This is over the number listed in Healthy People 2010 as the baseline, 208 and the goal of 166.

This project focused on enhancing the knowledge, skills, and practice of quality improvement strategies at the Johnson County Community Hospital (JCCH) and the physicians’ practice located at JCCH called the Johnson County Medical Group (JCMG). The project introduced process improvement using measurements related to diabetes in year one and has now turned their focus to CVD for the second year of operations.
Through partnerships with stakeholders including Mountain States Health Alliance, a health system serving Northeastern Tennessee and Southwestern Virginia, and East Tennessee State University (ranked third in the nation for their graduate program in Rural Health) the project has the foundation necessary to positively impact the health of the people in Johnson County.

In the first eight months of the first year of operations, we have uncovered several opportunities for improving the care delivered to the diabetic patients. In the clinic, these issues have undergone their first Plan-Do-Check-Act cycle and the results have been very promising. Interviews with the patients have revealed major issues with how patients view their overall health and the treatment of their condition. This has led to other opportunities for improving the health of the community through education and outreach. Throgh application of the QI methodology and through the sharing of efforts, results, and improved processes with other rual health care providers we will demonstrate improved patient care for the residents of Johnson County and provide a model for the surrounding region.

Logansport Memorial Hospital
Logansport, Indiana

The purpose of the Logansport Memorial Hospital Quality Improvement - Patient Registry Program (Quality Improvement Program) is to improve the health outcomes of chronic disease patients that the hospital and associated primary care providers serve within the five-county service area. Through the activities of the Quality Improvement Program it is anticipated that individual patients’ participation in personal disease management will improve/increase, which will ultimately improve patient outcomes and most importantly will enable patients to maintain a quality of life that allows both pleasurable and independent living.

The target population for the Quality Improvement-Patient Registry Program will be all patients of Logansport Memorial Hospital's Physician Office Practices, which includes: Logan Internists (Dr. David Morrical, Dr. Cherie Bennett, Dr. Anthony Fagbami), (Dr. Mark Crowley), River Bluff Family Medicine (Dr. Stephen Sauer) and Logansport Primary Care Associates (Dr. Charles Rogers). The preponderance of patients will originate from Cass County, Indiana, with some patients from the surrounding counties of: Fulton, Carroll, White, Miami, Pulaski and Howard. All chronic diseases patients served will benefit from this program.

Through the patient registry system patients with diabetes and cardiovascular disease will be more closely monitored. As a result the patient will be more aware, more educated about their chronic disease, more in touch with their care team, and more likely to be compliant with medical treatment. Regular visits with their physician will insure regular blood pressure monitoring for both diabetics and cardiovascular patients. At the same time, the patient's weight, diet, smoking habits, cholesterol level, hypertension, physical activity, and stress can be evaluated. Through this program the risk of developing complications and the severity of those complications will be decreased by effective metabolic control, regular examinations and patient education. These processes will help to reduce the death rate for diabetic and patients with cardiovascular disease.

Daviess Community Hospital
Washington, Indiana

The purpose of our proposed project is to assess health care provision at the Daviess Martin Medical Clinic, to identify aspects that could benefit from quality improvement activities, and to develop and implement strategies that will improve the quality of patient care and chronic disease outcomes. The target population for year one of the grant period will be the 135 Medicare patients of Daviess Martin Medical Clinic (DMMC) who have a diagnosis code for diabetes mellitus. The additional target population for year two of the grant period will be 150 of the approximately 800 Medicare patients of DMMC who have a diagnosis code for cardiovascular disease.

Tilden Community Hospital Rural Health Clinic
Tilden, Nebraska

The goal of this project is to assist rural health care providers in the implementation of quality improvement strategies by providing the tools necessary to improve patient care and chronic disease outcomes. The utilization of measurement tools, a national patient registry system, tracking and reporting specific health indicators using nationally accepted clinical performance measures, developing additional performance measures, assessing the need for quality improvement; and the ability to track changes over time are integral components to the concept of continuous quality improvement in patient care. Training rural health providers and allowing participation in a technical assistance workshop with fellow Small Health Care Providers, facilitated by a quality improvement specialist, is a benefit that most rural area providers do not have the opportunity to participate in. The impact for neighboring rural providers is that it will set up a model rural health provider performance measurement system, test resources needed, recruit resources not available related to limitation of funds, educate current licensed and volunteer providers, and provide education to the community regarding the importance of coordinating diabetes management and cardiovascular disease health indicators while applying national performance measures in the rural setting.
The rural areas of Northeast Nebraska, specifically the underserved areas surrounding Antelope County, will benefit from and be involved in the activities carried out by the Tilden Community Hospital Rural Health Clinic quality improvement activities. This grant will allow Tilden Community Hospital Rural Health Clinic to provide for the planning and implementation of small health care provider quality improvement activities. Tilden Community Hospital Rural Health Clinic will have the opportunity to demonstrate to other rural providers that there are improvements that can be made in the rural areas with limited funding regarding patient care. The utilization of national performance measures patient tracking and reporting will be initiated with the diagnoses of Diabetes Mellitus and cardiovascular disease. This system will allow the adopting of an integrated, prioritized approach to addressing patient health needs at the rural community level; establish a stronger quality improvement support structure to assist rural health systems and professionals in acquiring knowledge and tools to improve quality; and enhance the human resource capacity of rural communities, including the education, training, and deployment of health care professionals, and the preparedness of rural residents to engage actively in improving their health and health care; monitor rural health care systems to ensure that they are financially stable and provide assistance in securing the necessary capital for system redesign; and invest in building an information communications technology infrastructure, which has the potential to enhance health and health care in other medically underserved rural areas.

Island Health Plan, Inc.
West Tisbury, Massachusetts

The Island Diabetes and Cardiovascular Disease Management Project (ID/CVDMP) will plan, implement and pilot successful quality improvement strategies that will improve patient care and health outcomes for adult year-round residents of Martha’s Vineyard who are diagnosed or at risk for diabetes mellitus (DM) and cardiovascular disease (CVD). The project will be managed by Island Health Care (IHC), Massachusetts’ first and only rural health clinic, located on Martha’s Vineyard (Dukes County), a currently designated medical Health Professional Shortage Area (HPSA.) A relatively new facility with high demand among the uninsured and underserved, IHC has yet to develop an organized and integrated approach to chronic disease management.

Among the 15,500 year-round population on the Vineyard, the majority have limited incomes and significant challenges accessing health services. Approximately 22% have incomes below 200% fpl and over 50% have incomes below 400% fpl. Very high rates (almost 20%) of uninsurance (close to twice the Massachusetts’ statewide rate) and a lack of access to specialty care combine with limited income to create significant barriers to health care.

Martha’s Vineyard is also home to the federal Wampanoag Tribe of Gay Head/Aquinnah, with 1,500 members, as well as a significant (2,000 – 3,000) Brazilian immigrant population. Statistics gathered by the Wampanoag Health Services and the Martha’s Vineyard Brazilian Health Report parallel the national higher prevalence of diabetes within the Latino and Native American populations. The uninsured, underserved, Native Americans and Brazilian immigrants comprise ID/CVDMP’s target population.

IHC will improve the quality of DM and CVD disease management in three areas: 1.) organized clinical treatment; 2.) comprehensive care management; and 3) patient education and self-management. The project will utilize a patient registry system, track and report six health indicators against nationally accepted performance measures, assess the need for quality improvement and develop additional performance measures, and participate in peer learning workshops with fellow grantees.

IHC is a member of the Cape and Island Diabetes Disparities Collaborative (CIDDC) and locally a long-time member and leader of the Dukes County Health Council, which represents health care interests of all segments of the community. The project’s advisory team, including representation from both organizations, will perform the role of maintaining consistent communication and seeking advice, feedback and participation.

ID/CVDMP will reduce the percentage unmanaged diabetes and cardiovascular disease for the target population, develop a set of disease management protocols to apply more broadly across the chronic disease spectrum, and through networks and linkages built into the project, provide a model for proven disease management quality improvement.

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