2005 Diabetes & Cardiovascular Care Collaborative

The Diabetes and Cardiovascular Care Collaborative was designed for teams from physician groups (IPAs and medical groups) and pilot practices to re-design care at the practice site for patients with diabetes and/or coronary artery disease.

Approach

During the collaborative, teams set ambitious performance targets for P4P-aligned measures then learned from each other and from experts about how to implement proven best practices to achieve those targets in 12 months. The curriculum was specific, nuts and bolts, about what works and what doesn't.

The collaborative also helped teams plan for the next step, sustaining and spreading successful changes throughout the organization. In the short run, CQC supports accelerated improvement in the systems that can earn groups P4P bonuses. In the long run, CQC strengthens clinical leadership and change management skills to sustain and spread system-wide improvements in patient care.

Curriculum

Getting the Most From Your Registry
Coordinating Effective Group Visits & Planned Care
Motivating the Patient: Patient Self-Management and Action Plans
Screening for Depression
Improving Medication Adherence
Learning the Components of the Chronic Care Model
Understanding and applying the Plan-Do-Study-Act (PDSA) Improvement Model
Moving from Testing Changes to Implementing Successes
Planning to Spread Change Within an Organization

Project Summary

Download the Final Collaborative Report

Measures

Download the Required Core and Optional Measures

Expert Panel & Faculty

Thomas Bodenheimer, MD
University of California - San Francisco
Dept. of Family & Community Medicine

Daniel Cusator, MD
Medical Director
St. Joseph's Heritage

Connie Davis, MN, ARNP
Former Assoc. Dir. for Clinical Improvement
Improving Chronic Illness Care
MacColl Institute for Healthcare Innovation

Susan Fleischman, MD
Former Clinic Director
Venice Family Clinic

Alan Glaseroff, MD
Medical Director
Humboldt-Del Norte IPA

Mike Hindmarsh, MA

Manager of Clinical Improvement
Improving Chronic Illness Care

Halsted Holman, MD

Professor of Medicine

Stanford University

Angela Sembera Hovis
Improvement Advisor

Jerry Langley
Associates in Process Improvement

Terry Raymer, MD
United Indian Health Service

Neil Solomon, MD
CQC Diabetes & Cardiovascular Care Collaborative Chair
NAS Consulting

Participants

Collaborative Members
Brown & Toland Medical Group
Hill Physicians Medical Group
Humboldt Del Norte IPA
Memorial Healthcare IPA
Palo Alto Medical Foundation
Physicians Medical Group of Santa Cruz
County
Santa Cruz Medical Foundation
St. Joseph Heritage Medical Group
St. Joseph Hospital Affiliated Physicians

Observers*
Bright Medical Associates
Diabetes Society of Santa Clara Valley
Greater Newport Physicians
John Muir/Mt. Diablo Health Network
Sharp Community Medical Group

*These groups participated as collaborative observers. Observers did not have a pilot physician site testing changes and submitting data to the project.

Schedule

Additional Information:

Project Summary

Measures

Expert Panel & Faculty

Participants

Schedule